Although Telehealth offers the promise to improve access to critical healthcare services throughout our state and positively impact economic development in rural communities, the vast diversity of our citizens and the wide spectrum of our healthcare delivery system demand partnerships of many stakeholders in order to effectively and efficiently utilize Telehealth technologies and achieve sustainability.

The Center for Telehealth (CfTH) at the University of New Mexico has had the opportunity to plan, develop and implement several Telehealth initiatives and in the process learned the value of collaboration. Barriers to collaboration relate to the perceptions by stakeholders of relinquishing control and not having individual needs met, particularly in the current competitive healthcare market. However, creating partnerships with key stakeholders can provide a "network of networks" that can still preserve individual organizational autonomy but, at the same time, 1) provide a framework for mutually beneficial collaboration, 2) develop standards for interoperability and operations, 3) share experiences and technical or clinical expertise when appropriate, 4) recommend common guidelines for Telehealth decision making, and 5) address issues that impact the entire network operations and its sustainability, as well as 6) serve as an intrastate, interstate and international point of contact. Furthermore, a state-wide or regional Alliance can be proactive and responsive to policies, procedures, regulations and legislation that may impact Telehealth, speaking with a more unified voice. Finally, an Alliance can assist in coordination of the application of state and federal resources or grants for Telehealth in a manner that best meets the needs of stakeholders, avoids unnecessary redundancy, strengthens the opportunities to obtain and maintain those resources, and facilitates their use effectively and efficiently. CfTH is leading and coordinating an effort to develop a Telehealth Alliance in a manner that will bring together key public and private partners in this collaborative initiative, creating a model for others facing similar challenges.

Presented at the American Telemedicine Association Annual Conference 2004 as a poster and published in ATA proceedings; Alverson DC, Kalishman S, Jacobs J, Saland L, Caudell TP, Saiki S Jr: Interactive Virtual Reality in Distance Medical Education. American Telemedicine Association 2004 Annual Meeting, Orlando, FL, May 2004, Telemedicine Journal and e-Health, 10(Supp. 1):S-43.

Eastern Aleutian Tribes, Inc. (EAT) is a tribal health organization, which provides healthcare services to eight villages/communities with villages spanning several thousand miles along the Alaskan Peninsula and the Aleutian Islands. Due to the remote location of many of these villages, access has been traditionally dependent upon travel by plane or boat and weather conditions conducive to this means of travel. Severe weather has rendered it impossible to physically access these villages for weeks at a time. Telemedicine has provided the bridge to access these villages. EAT has expanded its telemedicine capabilities, incorporating both behavioral health and psychiatric services. This presentation will provide information about how EAT is utilizing telemedicine technology in support of telebehavioral health and telepsychiatry services.

EAT Psychiatric Consultation Services is presently comprised of one psychiatrist and two psychiatric nurse practitioners. Telepsychiatry technology provides for immediate contact between the psychiatric consultant/provider and each site/multiple sites (eight villages and administrative site) to deliver direct clinical services with patients for psychiatric evaluations, assessments for biological and psychosocial interventions, and follow-up services for comprehensive and specialty care. This medium is also being used for consultation and collaboration among providers to promote and enhance quality and standards of care.

Tele-behavioral health includes our broader mental health/substance abuse treatment services known as Behavior Health Services. These services refer to the clinical applications of individual therapy, family therapy, crisis intervention and supportive counseling. The only access to most of these villages is by boat or plane. These remote villages withstand 100 mile winds- leaving it impossible to fly in or it for weeks at a time, In times of severe weather we can provide access of services to the client by tele-video and enhance the clinical provider's schedule to provide a higher quality and more complete continuity of care to the clients we serve. Since October 15th, 2003, we have had 58 sessions from our pilot site in King Cove. Sessions have included adults, children, and at least one family.

Supervision marks another use, less common for tele-video. EAT employs 7 Village Based Counselors at the para-professional level in need of site clinical supervision. As a result of the tele-video equipment, supervision can be given face-to-face in the smaller villages. Tele-video has opened the door to an innovative way to do Clinical supervision. Village Based Counselors of the smaller villages may access face to face clinical support and supervision- pretty much on the spot. Sessions have been videotaped which extenuate the relationship between the client, Village Based Counselor, and Clinical Supervisor. Videotapes were used for training purposes for the VBC's.

There are many efforts in 2004 in Alaska attempting to move the field of telemedicine/ telehealth forward and taking steps to assure that it will assume what we know to be its rightful place in health care.

Telehealth currently has geographical and institutional representation from the north, southeast and west, from universities, private and public and military sectors. Regardless of where we are globally, we are embarking on a common, important, and ambitious journey.

Based on our best assessment of the state-of-the-art, our hope is to develop research policy, and action agendas sufficient to support comprehensive regional, national and international telehealth programs. In brief we need to:

• Continue to evaluate the status of telemedicine/telehealth
• Determine major issues facing the development of telehealth, and
• Develop priority areas, agendas, and action plans for research and development at international levels.

We want to know where we are and where we go from here, importantly; we want to develop a map of how to get there. We will do so on the basis of scientific evidence, rigorous methodology, and critical assessment. The networking and planning taking place at this conference represents a potentially very important development in the "last mile" of telehealth. By this we mean bringing it into the mainstream of health care by fulfilling its many promises. We should strive for a sound set of recommendations that will set the stage for a robust move forward for telehealth at the state level that will compliment regional, national and international health care arenas.

We must not think of telehealth only in terms of serving remote or otherwise medically disenfranchised populations. To do so would only relegate telehealth to a second tier or level of medical care but would also ignore its capabilities for system integration and coordination as well as efficient production of health.

In the 1970s The NASA Application Technology Satellite 6 (ATS-6) afforded an early opportunity to evaluate the effectiveness of advanced communications technology in supporting three types of non-physician primary care providers - nurse, physicians assistant, and Community Health Aide (CHA) - in a truly isolated environment.

The Alaska ASTS-6 Telemedicine Project was planned to be smoothly integrated with the existing health care system with the following objectives: (1) test and assess the technology capabilities to assist the physicians (including specialists) in providing supervision, guidance, and diagnostic support the for non-physician providers at remote locations; (2) test the ability of indigenous CHAs to effectively operate and use the equipment; and (3) evaluate the interactive video for consumer and continuing education.

The results of the study will be briefly summarized, and the (perhaps overlooked) pertinence of the conclusions and of the Alaska Native Health Service health delivery system model to current and future rural health care delivery will be presented. The evaluation methodology will be reviewed and the efficacy and deficiencies will be constructively noted.

Dr. Brown is an emergency physician. He is the founder and Executive Director of the NORTH Network Telemedicine Program which he has been developing since 1993. NORTH Network has recently completed a two-year, $20 million expansion making it one of the largest and most advanced telehealth networks in Canada.

Dr. Brown currently sits as a board member of the Canadian Society of Telehealth and as a member of the Operational Space Medicine Advisory Panel of the Canadian Space Agency, Astronaut Office. He also currently sits as a member of the Toronto District Health Council Systems & IT Task Force.

Dr. Brown is the recipient of the 2003 CANARIE I-WAY award for national leadership in the development of Canada's information highway, 'Application of Technology' category. He is also the winner of Canadian Healthcare Manager magazine's 2003 'Who's Who in Healthcare Award' in the 'Technology' category.

Prior to founding NORTH Network, Dr. Brown was Associate Faculty at the Institute for Clinical Evaluative Sciences in Ontario (ICES). Before embarking on his medical career, Dr. Brown studied mathematics and engineering at the University of Waterloo and worked as a Systems Engineer at IBM Canada Ltd.

The United States Coast Guard has more units located in remote locations than any other branch of the Armed Forces. Because of their remote locations, most Coast Guard units lack access to a full spectrum of healthcare services. This presentation is intended to share our experiences and lessons learned with others interested in store and forward telehealth systems.

The remote locations of our Coast Guard units create unique challenges for the Health Services personnel assigned to support them. Providing health services onboard a Coast Guard Cutter is even more challenging. To assist our remote clinics and Independent Duty Technicians in their delivery of health service, we have deployed the Alaska Federal Health Care Access Network (AFHCAN) Cart system to 4 clinics, 2 isolated LORAN transmitting stations, and one of our most remote Coast Guard Cutters. Future deployments will include several Alaska Coast Guard Cutters and our LORAN Station at Attu, AK. Although telehealth applications for the Coast Guard in Alaska are still in their infancy, our lessons learned are numerous and can be applied to other organizations interested in store and forward telehealth applications.

We've worked through un-wavering network security requirements, dealt with strong resistance to change and overcome a steep technology learning curve. However, when everything does come together, it only takes a single case to quickly illustrate the great potential this technology offers.

Sam Burgiss, Ph.D., is the Director of the University of Tennessee Telehealth Network at Knoxville. Under his direction, the UT Telehealth Network has developed the methodology for providing health care using telemedicine and telehealth techniques, and has provided patient services for over eight years to the population of East Tennessee. This program concentrates on medical care and has clinical sites where patients are visited by remotely located providers, school sites, and over 60 home sites. Since the beginning of year 2000, the program has provided over 70,000 patient encounters.

Sam is also involved in national issues concerning telehealth. He is on the Board of Directors for the American Telemedicine Association (ATA). He has served as Chair of the ATA Home Telehealth Special Interest Group for four years, and is a member of the ATA Public Policy Committee. He has witnessed to Congress twice to obtain better Medicare reimbursement, and is a member of the Coalition for the Advancement of Telehealth composed of the leaders of telehealth programs in eight states who address national policy issues.

Dr. Burgiss received his B.S., M.E.E., and Ph.D. degrees in Electrical Engineering from North Carolina State University. He has had over fifteen years of experience with medical products in software and computer design, engineering management, project management, and marketing in addition to nine years of telehealth experience.

Home Telehealth includes many care services that can be delivered to the residence of the patient using telecommunications. These services include the traditional ones offered by home care agencies and rapidly emerging services such as disease management. Technology used in Home Telehealth consists of primarily patient monitoring devices and systems to provide videoconferencing to the homes. Patients may have only monitoring services, only videoconferencing, or both depending on their need. Technology is constantly changing in this rapidly growing field.

Projects in providing home care using telehealth technologies have provided significant results in the quality of care and the reduction of cost. Assisting patients with chronic disease in self-managing their conditions is a primary opportunity for home telehealth. Outcomes can be both beneficial to the patient and the health care industry.

Future technology for home telehealth will depend on telecommunications infrastructure in the homes and anywhere that patients are located. As we look at the rapid expansion of telecommunications in the recent past, the predictions for the future are almost unlimited. Home Telehealth needs innovative thinking by clinicians and technologists as it matures into a major service for patients.

Pescadores, or the Pengus Islands, a group of 64 small islands that comprise a county of Taiwan, population totaling 90,000, area approximately 130 squared kilometers, is located in the middle of the Taiwan Strait, surrounded by warm but strong ocean currents.

As the national health insurance (NHI) program implemented in 1995 in Taiwan, the residents of Pescadores, along with those living in the mountainous areas and other off-shore islands, were not enthusiastic about it: medical resources were scarce, no doctors at all in many of those areas. "Health for All", a slogan for the NHI program, rang shallow there. They, many weak and fragile, were the underserved.

A few years later as NHI taking hold and becoming a popular program in the homeland, the situation in the remote and offshore areas seemed to begin to change. Beginning November 1998, an integrated delivery system (IDS) was introduced by the Bureau of NHI into Pescadore, along with several similar programs in the remote and offshore areas. An IDS was to be organized and coordinated by a major hospital, who would send out specialists along with other medical personnel to those underserved areas, and the local public village clinics became the backbone of the system, and, aided with financial and human resources, would provide primary care, and saw to it that there would be a doctor stationed in each of the major islands at all times.

A better referral system was then established between the small islands and the two local hospitals in the largest island Ma Kung. For severe and emergency cases, the patient will be taken back to the homeland via helicopters, or, for some case, treated by a telemedical system operated by a major medical center closest to the area. Preliminary surveys indicated high approval rates for the IDS.

Ms. Connell currently serves as legislative assistant to U.S. Senator Ted Stevens (R-Alaska). She handles all issues relating to health policy and legislation, Medicare and Medicaid, welfare and education as well as Native issues for Senator Stevens. A major part of her efforts have been devoted to legislative, regulatory and advocacy efforts to gain Medicare coverage for emerging medical technologies, including positron emission tomography (PET). Ms. Connell drafted legislative language setting forth a framework for the Food and Drug Administration to oversee radiopharmaceuticals used in PET which was included in the FDA Modernization Act of 1997 and which led to the Department of Health and Human Services initial favorable coverage decisions for PET. She has played an active role on hehalf of Senator Stevens in issues important to Alaskans, including the Alaska Federal Telemedicine Project, alcohol and substance abuse programs and issues relating to the Alaska Native health system.

From 1989-94 Ms. Connell worked as an independent consultant in health care finance and managed care, including an AID-funded project to assist the Indonesian Ministry of Health reform its health care system.

From 1986-89 Ms. Connell served as a senior level political appointee in the Department of Health and Human Services (Executive Secretary to the Department) during the Reagan-Bush Administration.

From 1978-85 Ms. Connell was president of the Life Insurance Association of Massachusetts, representing the life and health insurance companies in Massachusetts. In that capacity, she played a key role in setting up a coalition of insurers, business leaders and health care providers which made major changes in the Massachusetts health care system.

In the early-mid 1970's, Ms. Connell was director of government and public relations for a Washington, D.C.-based health care trade association which represented investor-owned health care facilities.

Ms Connell received an MBA from Harvard Graduate School of Business Administration in 1976, and an AB from Cornell University (Government and History) in 1967.

Various factors lead to the decision by hospital CEO's, administrators, and health care providers to implement telehealth technologies into the services they provide. In Kansas, eight communities have recently invested in telehealth systems to access specialty clinical services and educational programs utilizing interactive televideo. Predominately, clinical services include adult and child psychiatry, child psychology, dietetics and nutrition, oncology, pediatrics and rheumatology. Educational services are routinely broadcast for continuing medical, nursing and allied health providers as well as community-oriented programs. The eight communities are now part of a broader network within the state that includes over 50 sites with similar telehealth capabilities.

For this study, 33 health care providers from the eight communities were interviewed to better understand the strategic decision-making employed in implementing telehealth capabilities. As a way of balancing and comparing these decisions with the population they serve, 191 patients who utilized the telehealth services from these same communities also were interviewed. Interview responses were transcribed and content analyzed. Financial and cost considerations from both urban and rural administrators were a primary motivator for participation. These findings wavered from previous research results from within the state, suggesting that the innovative nature of telehealth and its unknown potential were equally salient factors within this decision process. Urban and rural health care providers cited access to services and quality of care as higher priorities in deciding whether or not to participate. Rural providers emphasized the importance of keeping patients locally to facilitate a high standard of care. Urban providers emphasized the ability to access patients otherwise not able to receive services. Patients were overall very satisfied with services; however, they consistently reported that their concerns or questions about telehealth were not considered by telehealth decision-makers. Results will be further discussed including their implications on the communities involved.

The purpose of telemedicine in rural healthcare delivery system is to help stem the shortcomings in the prevention, Management and treatment of prevalent diseases especially in developing countries like Cameroon.

Telemedicine can be defined as the provision of quality healthcare services using telecommunication and information technology devices. If well adapted in our rural healthcare delivery services it will become an important step in lessening the sense of isolation always felt by healthcare workers working far from advanced medical centres which are always located in one or two main cities in most developing countries across Africa. Hence Telemedicine is an essential tool in the delivery of quality healthcare services in Cameroon.

Our foundation (RCHF) in Kumba, Cameroon emphasizes on the appropriate diagnosis and treatment of prevalent diseases in our rural communities e.g. Malaria, Filaria, Typhoid, STDs and TB and also the fight against HIV and AIDS.

In rendering our services to the rural dwellers we face many difficulties, e.g. Lack of patients awareness to report for treatment early immediately the first symptoms appear, very poor road infrastructure prevents us from reaching patients in remote villages for regular follow-ups and also patients to report promptly for medical attention in the centre. Poverty and patients non compliance with treatment regime for malaria, Typhoid, T.B and Filaria. Lack of quality medications and proper education. Drug abuse and superstitious beliefs in witchcraft.

I believe that Telemedicine if properly adapted to our rural healthcare delivery system in Cameroon will help us overcome most of the problems highlighted above and thus adding quality to it. A knowledge gained attending this conference is very relevant to the improvement of our rural healthcare delivery services because on my return to Cameroon I have to share with my other colleagues to reflect on how best we can adapt Telemedicine to our healthcare system to make it respond to present global challenges.

The Kimberley region of Western Australia is as remote as Alaska but instead of being separated from the rest of the country by another country, Canada, it is separated by a vast expanse of desert. It has 2 main towns with populations between 8,000 and 12,000 people, 4 smaller towns and a large number of Indigenous communities and outstations.

Lower limb ulcers are a significant cause of morbidity in the Kimberley. Amputations are the end result of a cascade of problems associated with Hansen's neuropathy, diabetes, venous and arterial disease associated with poor lifestyle choices. Unhappy with this seemingly inevitable outcome it was decided to assess the quality of wound care being received by patients in the outpatients setting. As a consequence of our findings we introduced the Alfred/Medseed Wound Imaging System (AMWIS) as part of a research project to assist staff to document and care collaboratively for patients with lower limb ulcers.

The project was to conduct a prospective randomized control trial to determine the efficacy of using digital wound imaging and remote consultation on the healing rates of lower limb ulcers of any etiology in the Kimberley Region of WA.

Nurses were required to make a detailed assessment of the patient's wound and document the care. They took digital photographs and inserted both the photograph and the care plan into a computer database package, AMWIS. In the intervention group the encrypted file was emailed fortnightly to a specialist wound care nurse, in a tertiary referral centre for comment.

This paper will discuss the cost of care associated with high rates of diabetes, peripheral vascular disease and neuropathic feet in a remote, highly mobile population. It will highlight the need to provide ongoing education to a generalist nursing population to be able to effectively manage lower limb ulcers. It will highlight the inherent difficulties of getting a research project up and going in this context and parallel this with assessing the cost and benefits of establishing best practice care for patients with lower limb ulcers.

Tele-psychiatry can be used clinically for both assessment and treatment, is effective for case conferencing and consultation-liaison work, supports educational and research applications, and can be incorporated into a range of service delivery models. There is a considerable amount of literature indicating that electronic video diagnosis and treatment is possible across a wide range of psychiatric disorders. Psychiatry is thought by many to be the specialty most suited for video consultations/ videoconferencing, and there is a substantial body of evidence that demonstrates the satisfaction that both practitioners and patients derive from this form of care.

Cedars-Sinai started the first tele-psychiatry clinics for the developmentally disabled in the state of California in 1997. One of the major clients for these services is Far Northern Regional Center (FNRC). FNRC's geographical area consists of 30,211 square miles in 9 northeastern California counties. Approximately 580,000 people inhabit this area. Most of this area is underserved by specialty medical providers. Much of this area is mountainous, and inclement weather and dangerous road conditions often prevent travel. From the farthest counties, it could take a whole day's travel for a patient to reach the university hospitals in Sacramento or San Francisco to receive necessary specialized medical assessment, evaluation or ongoing treatment. Between January 2002 and March 17, 2003, Cedars Sinai has provided approximately 230 tele-psychiatry consults to FNRC.

The approach has been one of collaborative consultation-liaison (C-L) between our psychiatrists and the primary care physicians. In approximately one third of the clinics an attending geneticist is also present. Forensic psychiatry fellows, pediatric residents, genetics fellows, social workers, early childhood trainees and medical students also participate periodically. Patients, parents, case workers, sometimes family practice residents on rotations, behavior therapists, teachers and others are at the remote telesites.

Stewart Ferguson Ph.D. is Director of the Alaska Federal Health Care Access Network (AFHCAN) in Anchorage, Alaska. AFHCAN is Alaska's largest telehealth project with deployments at 248 remote sites, and has been recognized with both the National Managed Health Care Congress' AstraZenca Award and the Grace Hopper Government Technology Leadership Award. Dr. Ferguson has been with AFHCAN since it's inception in 1998, served as both Technical Director and Deputy Director for the project, and was responsible for the design of the hardware platform supporting the biomedical devices. He also had key roles in product/software development, assessment, evaluation and research. Prior to the AFHCAN Project, Dr. Ferguson served with the Alaska Native Health Board as CTO for the Village Telemedicine Testbed Project - a project funded by the National Library of Medicine that deployed telehealth solutions to 26 remote Alaska clinics and 4 regional hospitals.

Dr. Ferguson has over twenty years of progressive computer and research experience in academic, industrial, biomedical and business environments. He has been involved in software development for CT scanners, theoretical solutions for the forward and inverse problems in biomagnetism, imaging techniques for cardiac activity, and was the owner/partner of two consulting firms in Cleveland and American Samoa specializing in custom software development, database design, and integrated network installations. He hold M.S. and Ph.D. degrees both in Biomedical Engineering, and B.S. degrees in Mathematics and Electrical Engineering.

The Alaska Federal Health Care Access Network (AFHCAN) recently completed its fifth year of operation and a vision of utilizing sustainable telehealth technologies to improve access to quality health care for Federal beneficiaries throughout Alaska. AFHCAN developed telehealth solutions through broad scale organizational collaboration and innovative technology to solve a common problem for Arctic nations: delivering local access to health care for sparse populations spread across large distances. 80% of the project sites are not located on the statewide road system, 75% of the sites cannot be reached by jet, and residents of these communities travel an average of 147 miles to reach the next level of health care.

The AFHCAN project delivered telehealth solutions to 248 sites, organized under 43 autonomous organizations. This represented enormous hurdles for developing a single solution that met the disparate organizational clinical needs and concerns for security, systems interfaces, training, and support. Moreover, these sites represented an enormous breadth of experience of providers: 32 of the 235 sites are staffed by physicians, while 163 sites are staffed by Community Health Aides (CHAs), who receive 16 weeks of basic medical training yet provide almost a half-million patient encounters a year.

To meet the disparate needs, AFHCAN developed a simplified assessment and planning process, and chose to focus on primary care needs. Statewide participation led to the development of a software / hardware solution that minimized the need for computer skills and complex training yet met the needs for each organization. The enterprise solution that was developed now allows autonomous health care organizations to share multimedia telehealth data in a controlled, secure and robust manner - without forcing changes in referral patterns.

The presentation will focus on the lessons learned from the design, development and deployment of a single telehealth solution in a complex organizational environment. A key focus is building on the success that has been achieved and looking to the future through a discussion of measured outcomes, impacts on clinical care, and potentials for collaboration.

Dr. Linda Godleski, MD, is the Veterans Health Administration (VHA) MidSouth Network Mental Health Services Manager and Telemedicine Coordinator, VISN 9. Additionally, in her capacity as national VHA Lead for Telemental Health, she chairs the VHA Telemental Health Field Advisory Work Group which has been instrumental in developing the VHA National Telemental Health Toolkit.

Dr. Godleski brings to the VHA a variety of experiences from a wide array of mental healthcare settings. She came to the VA from a position as Medical Director of the Connecticut Mental Health Center at Yale. Her prior positions include Director of the Psychosocial Rehabilitation Unit at the University of Hawaii's State Hospital, Director of the University of Virginia's Psychiatric Research Unit at Staunton's Western State Hospital, and solo private practice.

Academically, Dr. Godleski is Associate Chair for Academic Affairs and Associate Professor in the University of Louisville's Department of Psychiatry. Previously, she was an Associate Professor at Yale Medical School and at the University of Hawaii's School of Medicine, in addition to prior faculty positions at the University of Virginia and the University of Central Florida.

Dr. Godleski has a Bachelor of Science degree from Yale University. She received her MD degree from the University of Virginia where she also completed her psychiatry residency.

Mental Health has been a leader in the use of telehealth technologies for decades. Lessons learned from these years of experience provide us with excellent guidelines for the future implementation and enhancement of telemental health services. Furthermore, as we move into the 21st century, the technology and infrastructure to deliver telemental health services have become even more accessible and affordable, yielding a new era of unlimited possibilities.

The Veterans Health Administration (VHA) provides one of the largest telemental health networks in the world, and serves as a model for best practices. In the past year alone, 13,840 telemental health encounters were delivered to 8370 veterans from 73 hospitals to 143 satellite clinics and 12 homehealth programs. While it was initially unclear which mental health services could be implemented using telehealth technologies, the VHA has demonstrated successful delivery of numerous treatment modalities including: medication management, individual psychotherapy, group therapies, substance abuse treatment, and specialty Post-Traumatic Stress Disorder programs. Telemental health services are delivered by all levels of mental health clinicians (psychiatrists, psychologists, nurses and nurse practitioners, physician assistants, social workers, etc). Diagnoses treated include psychotic, affective, anxiety, and substance abuse disorders. Desktop video as well as high powered video conferencing equipment is used to connect to satellite clinics typically using 384kbits bandwidth over T-1 lines. Home telemental health programs use videophones, home messaging devices, and interactive voice response (IVR) over traditional plain old telephone lines (POTS). Details of these programs and services will be presented with lessons learned and clinical practice guidelines.

The large expanse of VHA programs created numerous challenges which will be discussed. Clinical issues addressed include: (1) how to handle emergencies when the patient is long distances from the parent telemental health facility, and (2) whether initial visits must be performed face-to-face even when the long distances are a substantial deterrent. Best practices were developed based upon information gathered from individual sites and disseminated throughout the nation.

The presentation will conclude by providing practical advice on how to access resources available to assist in the development or enhancement of telemental health services, using educational materials, websites, and an extensive reference bibliography.

Mental Health has been a leader in the use of telehealth technologies for decades. Lessons learned from these years of experience provide us with excellent guidelines for the future implementation and enhancement of telemental health services. Furthermore, as we move into the 21st century, the technology and infrastructure to deliver telemental health services have become even more accessible and affordable, yielding a new era of unlimited possibilities.

The Veterans Health Administration (VHA) provides one of the largest telemental health networks in the world, and serves as a model for best practices. In the past year alone, 13,840 telemental health encounters were delivered to 8370 veterans from 73 hospitals to 143 satellite clinics and 12 homehealth programs. While it was initially unclear which mental health services could be implemented using telehealth technologies, the VHA has demonstrated successful delivery of numerous treatment modalities including: medication management, individual psychotherapy, group therapies, substance abuse treatment, and specialty Post-Traumatic Stress Disorder programs. Telemental health services are delivered by all levels of mental health clinicians (psychiatrists, psychologists, nurses and nurse practitioners, physician assistants, social workers, etc). Diagnoses treated include psychotic, affective, anxiety, and substance abuse disorders. Desktop video as well as high powered video conferencing equipment is used to connect to satellite clinics typically using 384kbits bandwidth over T-1 lines. Home telemental health programs use videophones, home messaging devices, and interactive voice response (IVR) over traditional plain old telephone lines (POTS). Details of these programs and services will be presented with lessons learned and clinical practice guidelines.

The large expanse of VHA programs created numerous challenges which will be discussed. Clinical issues addressed include: (1) how to handle emergencies when the patient is long distances from the parent telemental health facility, and (2) whether initial visits must be performed face-to-face even when the long distances are a substantial deterrent. Best practices were developed based upon information gathered from individual sites and disseminated throughout the nation.

The presentation will conclude by providing practical advice on how to access resources available to assist in the development or enhancement of telemental health services, using educational materials, websites, and an extensive reference bibliography.

David Guggenbuehl is the director of Regional Services at Gundersen Lutheran Medical Center in La Crosse, Wisconsin. He oversees the development of Gundersen Lutheran's regional provider referral market, with specific emphasis on physician relations, specialty outreach, mobile diagnostic services, telemedicine program development, network expansion, and regional hospital relations. He is the chairman of the Gundersen Lutheran Corporate Sales team as well as the Telemedicine Development Committee.

Guggenbuehl has been employed at Gundersen Lutheran for over twenty years, with over fifteen years experience in regional physician network development. He obtained his BSN at Viterbo University in La Crosse and has several years of critical care nursing experience. He is presently a candidate in the MBA Program from Cardinal Stritch University of Milwaukee, Wisconsin. He recently served a term on the Gundersen Lutheran Health board of directors. He has spoken at several national conventions on the subject of referral relations and has also been a featured speaker sponsored by the National Health Service in the United Kingdom.

Introduction: Gundersen Lutheran Medical Center is one of the leading specialty referral centers in the United States in exporting its specialists to rural areas within a one hundred mile radius around La Crosse, Wisconsin. Over 125 specialists provide at least one or more outreach clinics throughout the region. The challenges associated with travel, productivity, staff shortages, access to specialists, and numerous other issues prompted the development of a clinical telemedicine service. The integration of clinical services with a fully established telehealth network seemed a natural fit for an organization which provides health services to over a half million residents in rural Wisconsin, Minnesota, and Iowa.

Methods: A business plan was developed to evaluate market dynamics, economics, technology, logistics, personnel requirements, and additional infrastructure support needed to build this program. Support from the Executive Leadership Group at Gundersen Lutheran Medical Center was obtained following a six month successful pilot program in Cardiology. Funding for the program was provided by the Medical Center's Foundation plus a $35,000 grant from the State of Wisconsin's Department of Public Services Commission.

Results: Gundersen Lutheran is presently providing clinical telemedicine services in medical oncology, radiology, cardiology, and behavioral medicine in five regional locations. Additional expansion is expected to occur in numerous other specialties and several additional locations.

Discussion: Issues related to infrastructure development, physician and patient satisfaction, program evaluation, and other related challenges will de discussed.

David Hailey has worked extensively in the field of Health Technology Assessment. He is a Professor in Public Health Sciences at the University of Alberta, Edmonton, a Senior Advisor to the Alberta Heritage Foundation for Medical Research and a Research Fellow at the Institute of Health Economics. He was previously Head, Health Technology Division, Australian Institute of Health and Welfare, Canberra. He is currently based in Australia.

Dr Hailey's work related to telehealth includes systematic reviews of evidence for the benefits of telemedicine applications and evaluation of telepsychiatry and teleradiology services. Current interests include the effectiveness of video-visits in palliative homecare and the assessment of telecardiology.

Telehealth deserves critical appraisal to determine its place in health care systems. Assessment of telehealth applications is needed to assist decisions on purchasing and planning and on approaches to health services and health education.

Assessment of telehealth has covered both process issues and outcomes. Consideration of process is important for ensuring that the application is viable and may be particularly related to local circumstances. Health technology assessment (HTA) provides a suitable framework to categorize and measure effects resulting from the adoption of telehealth, and to provide a synthesis of these as input to future decisions. A telehealth application is compared with an alternative approach in terms of attributes such as safety; efficacy (performance under optimum conditions); effectiveness (performance under routine conditions); economic impact ; and access. Initial assessment of a telehealth application will be related to making a business case. Details will be required of the population to be served, existing services, equipment specifications, delivery arrangements, personnel requirements and costs.

Subsequent evaluation of the telehealth application will consider the initial use of the service and then progress to longer term, follow up appraisal. Elements covered will include technical assessment, measures of effectiveness, economic efficiency and also the sustainability of the service, having regard to local health care arrangements and preferences of users.

While, ideally, optimum study designs and detailed studies should be used to appraise telehealth applications, as with any health technology assessment the approach taken must be tailored to the questions and needs of decision makers. Also, in practice, assessment approaches will be influenced by availability of data and local evaluation expertise.

Several systematic reviews have drawn attention to the poor quality of evidence available on the costs and benefits of telehealth applications. However, better quality studies are starting to appear and shared experience by researchers has provided some useful insights into determinants of success and failure in telehealth.

Because Alaska is very large and has a sparse but mobile population, Alaska has always pushed the limits of its limited telecommunications infrastructure for performing healthcare. In 1974 the Alaska Area Native Health Service began developing an inter-facility data sharing system based on microfiche distribution of composite health summaries. It was replaced in 1990 with an electronic system called Multi-Facility Integration (MFI).

MFI is a module of the Resource and Patient Management System (RPMS), the automated medical records system provided by the Indian Heath Service. It transfers encounters to other facilities that provide care for the same patient and maintains a system wide database.

MFI processes over 1 million encounters per year with data for 195 Alaska Tribal Health System (ATHS) facilities. About 80% of the ATHS encounters currently reside on MFI and there are plans for adding the rest.

While most RPMS sites in Alaska cannot currently handle images, a new version this year will allow the inclusion of images in the record. This allows the proposed interface between AFHCAN and RPMS/MFI to handle images as well as text information about the AFHCAN encounter. This is one more enhancement to serve the ATHS beneficiaries and gets us one step closer to complete coverage of the population.

We have set up a pilot study to evaluate the use of teleclinics using videoconferencing to reduce the number of vascular outpatient attendances.

Since April 2001 all patients from one general practice with non-urgent vascular problems have been seen via the teleclinic with prior electronic transmission of data to the vascular consultant in an agreed proforma which included digital photographs and ankle/brachial pressure indices where appropriate. The patient was assessed and further investigation and management discussed with them during the teleclinic and carried out in a conventional manner with hospital attendance. Any follow-up was via a teleclinic.

12 patients have been seen via a teleclinic. Their median age was 76 years (30-94) and mean conference time was 10 minutes. 6 patients had leg ulceration of venous +/- arterial aetiology, 3 patients had complications associated with varicose veins, 2 patients had claudication and 1 patient possible upper limb arterial disease. Teleconferencing enabled appropriate evaluation in the vascular laboratory to be arranged in all cases without attendance in the hospital clinic. 5 patients have had intervention and follow up by teleconference.

Teleclinics, in conjunction with electronic proformas and digital photographs, can replace conventional outpatient attendance for many vascular patients. Adoption of teleclinics reduces the stress and cost of hospital attendance and alleviates pressure on outpatient clinics. Increasing hospital workload from the expanding elderly population has to be met with new strategies if we are to maintain a quality health service. Our results suggest that vascular teleclinics should be part of this strategy.

To gain maximum benefit from the use of Information Technology (IT), decision makers must create efficient ownership of technology, focusing on using IT to meet the needs of both patient and provider populations. Eastern Aleutian Tribes (EAT) developed Alaska's first dual funded (IHS and CHC) model for providing "safety net" access to primary care for underserved populations. EAT services six frontier Alaskan communities with a permanent population of approximately 2,500 people with an increase of over 8,500 additional people during the peak fishing seasons. Each of these communities is geographically isolated from one another in the Aleutian region of Alaska (6,988.1 sq. miles of land and 8,023.5 sq. miles of water). EAT also provides primary care clinics in Adak and Whittier, the only source of health care in those communities. Our goals:

1. extending and improving access to health care service and health information using new telecommunication and telemedicine technology,
2. becoming an IT model and resource for Alaska and other rural communities, and
3. partnering with borough, tribal, and city organizations to share both human and network resources.

To this end, all eight of our communities are equipped with telemedicine carts and servers. The cart system includes dental camera, EKG, video-otoscope, digital imaging, and connects server to allowing cases to be sent to the EAT clinic network or to specialists within the Alaska Native Medical Center (ANMC). All sites have video conferencing allowing point to point and multisite real time interaction. Conferencing is used for administrative facilitation as well as mental health counseling/supervision. Seven communities have a telepharmacy system in place and two community clinics have teleradiology with Dicom bridge compression and transmission of radiographic images to multiple specialties at ANMC. Internet Protocol (IP) telephony is now in place at one site improving bandwidth use for text and voice.

The Fetal TeleUltrasound Project began in 1998 as a concept to provide in-area specialty health care to women with high risk pregnancies who live on the neighbor islands within the State of Hawaii. The Maternal Fetal Medical Specialist Physicians are based in Honolulu on the Island of Oahu. Therefore, women who needed this care who live on the Neighbor Islands previously had to either travel to Honolulu for an exam or wait until one of the MFM's traveled to their home Island.

The Research and Development Phase of the Project included working with several video conferencing technologies and vendors to come up with a solution that met the requirements for remotely viewed live fetal ultrasound images equal to, or better in quality than viewing the exam images directly at the ultrasound machine. Another key requirement in the technology development was the ability for interaction between the Physician, Remote Ultrasound Technician, and Patient for quality examination results.

Fetal TeleUltrasound now provides a Telemedicine alternative for women with High Risk Pregnancies in Hawaii who live outside of urban Honolulu. The Fetal TeleUltrasound Service from Kapiolani's Medical Center for Women & Children Fetal Diagnostic Center went live on March 1, 2001. Today, Fetal TeleUltrasound is fully integrated, billable, and reimburse-able clinical service providing real time remote fetal ultrasound exams to nine rural sites on all major Hawaiian Islands. The Fetal TeleUltrasound Project is the baseline for expanding Telemedicine services from other Specialties within Hawaii Pacific Health's facilities to rural areas of Hawaii and the Pacific.

The presentation will cover development of the project funding, technical solution, partner site selection, key success criteria, number of patients, patient survey data, project outcomes, and patient success stories resulting from the availability of this service.

As a specialty that depends heavily upon images, ophthalmology provides many opportunities for utilization of telemedicine techniques. Teleophthalmology capability is moving rapidly to include virtually all aspects of ophthalmic evaluation, making comprehensive eye examination equivalence by telemedicine an increasingly possible goal. Remote evaluation of diabetic retinopathy is the most mature teleophthalmology modality with several commercial applications available. This is likely to continue as a dominant category within the larger domain of teleophthalmology. IHS experience with such a system has been favorable and credited with significant increases in adherence to standards of care for patients at risk for diabetic retinopathy. A brief discussion of this experience is provided.

The current status of teleophthalmology is discussed and future steps are considered. Increasing access to care as the classical motivator for implementing telemedicine is considered in the context of other opportunities. An emphasis on implementation of teleophthalmology as a quality initiative is provided. Similar technological shifts for quality improvement in non-medical industries are discussed as examples of how evolution of technology coupled with structured changes in professional culture can result in enhanced quality of service.

The Arizona Telemedicine Program, established in 1996 through the University of Arizona's College of Medicine, has mushroomed into a "network of networks" which spans a multi-state infrastructure, and which was named the best in the country by the American Telemedicine Association.

This presentation will discuss the Arizona Telemedicine Network and its infrastructure, how it functions, the services it provides, including infrastructure maintenance and the delivery of health care, and lessons learned in its implementation.

In its initial development stage it was important that the network organizers be sensitive to traditional patient referral patterns, in order not to be perceived as wanting to disrupt or scoop up referrals for the benefit of the host institution. Eventually, as the network grew, it became evident to its users that patient referral patterns were the organizing link in designing an infrastructure to meet the needs of its users. Today, the Network backbone links corporate health systems to their partners in remote areas for the delivery of care. Examples of users include the Indian Health Service, Carondelet Health System, and the Arizona State Prison System.

In addition to providing Network infrastructure services to other users, the Arizona Telemedicine Program also delivers specialty care between the University of Arizona College of Medicine, and rural hospitals and clinics. Telepsychiatry, teledermatology, telecolposcopy, teleophthalmology are among the specialty services delivery. Over time, the Telemedicine Program leadership has identified a number of challenges, which impact user efficiency and patient access to services. These include turnover of hospital chief executives and chief medical officers, in particular, the telemedicine "champions" who do not necessarily mentor a replacement before they move on. Also among the challenges are the importance of providing user training in telemedicine system protocols, as well as the types of cases that are conducive to telehealth consultations.

This presentation will discuss these and other lessons learned over the six years of implementing the Arizona Telemedicine Program.

The following abstract will focus on a five-year program of evaluation and treatment of children who have allegedly been abused. Through telemedicine technology, the children of North and North Central Florida are being protected due to rapid turn around provided by a large telemedicine network that has been established. Four hub sites and eight remote sites cover Florida from the Florida-Georgia line south to the middle of the State near Walt Disney World.

The telemedicine project is a coordinated effort of the Medical Director of the statewide Child Protection Team, The Department of Management Services, Florida Department of Health, and the University of Florida, Department of Pediatrics on the Jacksonville Campus and on the Gainesville Campus. The network link between the two university locations will be discussed. The session will show how evaluation of child abuse can take place 24 hours per day, 7 days per week and cross many miles and county lines. Telemedicine reduces the numbers of children needing transportation to the urban areas from the rural areas by law enforcement and the Department of Children and Families thereby saving their departments time and money. The technology increases the numbers of successful court actions by improving access to expert witness testimony. Video conferencing reduces the time spent in travel for team and regional meetings, peer review with the statewide medical director, and training for local DCF and law enforcement agencies.

The second focus will be on the equipment. This program uses Tandberg products, Circon Colposcopes, AMD Handcams and ImageQuest Software. An introduction to the equipment and cost of the equipment will be covered. An overview of the establishment of protocols for using the equipment will be available.

The third focus will be on the actual exam. The audience will be given pointers on lighting, introduction of the exam to the client and actual experiences from over 400 exams done in the past 5 years. Evidence collection will be included. Professionals interested in child abuse, law enforcement officers, CPS workers and those working in information technology will benefit from this program by enhancing their knowledge of telemedicine in general. The professionals will recognize how telemedicine will benefit their community as well as gain ideas and methods on how to begin a program.

The ENT Department at Alaska Native Medical Center in Anchorage, AK serves a large geographic area, and has incorporated store and forward telemedicine in its practice over the last 5 years. Our experience is recounted in developing this service and in processing over 1200 cases in the past year. In the previous 9 months, the ENT department has managed to conduct 20-60 store and forward cases per week with no impact on other staff workload, equivalent to adding a 0.5 FTE providing Specialty Clinic services to rural Alaskans at no additional personnel cost to the department.

With the application of telehealth technologies to deliver care to rural areas, the waiting time for services at both ANMC and regional facilities has been drastically reduced. Telehealth technology is now being used to provide and augment Audiology services at the village level and provide faster, more cost efficient delivery of services. This has improved access for specialty care at the village level. Outcomes analysis of this service demonstrates that unmet need for care is now being addressed.

The spectrum of ENT care that we now offer by store and forward telemedicine will be demonstrated. Pitfalls and lessons learned in developing and implementing this unique service are discussed.

Telemedicine and telehealth development have brought hope to the developing countries and their most remote areas as they strive to become part of global medical community. Telemedicine project of Kosova is the best example of successful establishment of telemedicine in developing countries. The idea of creation of Telemedicine project of Kosova and International Virtual e-Hospital Network (IVeHN) of Kosova was introduced at the G-8 final meeting in Berlin in May 2000 by the author, and accepted by Kosova's medical community at the First International Symposium: Medical Emergencies During Military Conflicts that took place in Prishtina, Kosova, December 28-30, 2000, and when the Telemedicine Association of Kosova was established.

After two years of intensive preparation the Telemedicine Centre of Kosova (TCK) and International Virtual e-Hospital Network of Kosova was inaugurated on December 10, 2002. This state of the art telemedicine facility located at the heart of the University Clinical Centre of Kosova (UCCK) in Prishtina, Kosova is placed in 1000 square meters of space and includes: a modern IT room with a server and electronic library, training and resource rooms, telemedicine rooms, a conference room, and a state of the art auditorium. The activities of TCK are coordinated within the structured collaboration with the Ministry of Health (MoH), Medical Faculty of Prishtina, UCCK, Medical Battalion of Kosova Protection Corps (KPC), and other educational and clinical institutions of Kosova and abroad. For the first phase of the project, the activities of the center have been concentrated mainly in educational programs, creating electronic library with more than 2000 electronic journals, implementation of telemedicine pilot project with regional hospitals and emergency centre of UCCK. In addition to this, creating the network between TCK and regional hospitals, and human capacity in preparation for phase two of the project which predicts creation of telemedicine centers in seven (7) regional hospitals in Kosova, and finally creation of international network of institutions and countries around the world.

The network will be used primarily for the education of medical doctors in remote areas, especially family physicians, general practitioners, and primary care doctors, as well as physicians in training at the UCCK, medical students at the Medical Faculty of University of Prishtina, and physicians and nurses at clinical centers and regional hospitals in Kosova. The TCK has four departments (technical, clinical, research & development, and finance). On October 25-27, 2002 the TCK and IVeHN of Kosova with its local and international partners organized successfully the First Intensive Balkan Telemedicine Seminar entitled "Telemedicine and Telehealth in Developing Countries; From Inception to Implementation. The Future Has Just Begun," with 400 participants from 21 countries.

To this end, TCK is fulfilling a huge gap in medical education of Kosova, which is a result of neglect, war and poor management. By using modern technology, TCK is bringing Kosova's medical care into the 21st century, in an attempt to reduce and narrow the education gap, and to improve the educational process of doctors, nurses, medical students, and other health care workers. For now, it is viewed as the penetrating eye of the future and of the unconventional, and as such will become the Balkan's Center of Excellence for Telemedicine. Telemedicine project of Kosova so far has been funded by the European Agency for Reconstruction, but much work is ahead to secure it long term sustainability.

The Alaska Clinical Access Network was conceived with the idea of developing a secure way for all healthcare providers of the State of Alaska to communicate. The network is being developed so that providers can communicate among themselves; health bulletins and important information pertaining to emergency medical situations can be broadcast effectively.

All healthcare providers will be assigned an account, and will not need to have an email account to use the system. The healthcare provider demographic databases will be maintained by each group of professionals. The Alaska State Medical Association will maintain the demographics for all physicians; the Alaska Nurse Practitioners Association will maintain the demographics for all nurse practitioners.

The project is currently preparing to deploy the first stage which has the demographics for physicians. To follow will be demographics for the nurse practitioners and subsequently the physicians assistants, nurses, podiatrists.

The network is accessible by any computer that has access to the Internet. No special software is required. An email account is not needed. A front page is available from the internet, with general information and bulletins. This area is open to the public. Following is a login section for members, providing secure messaging. Forms for inserting medical information are being developed. Security for the system meets all of HIPAA's requirements for transfer of medical information.

The initial funding for the project has been provided by the Alaska Telehealth Advisory Council, the State of Alaska and the Alaska State Medical Association.

Once the system is functional and offering value to the community, charges will be assessed to allow the system to become self-sustaining.

Liz Loewen is Network Researcher with MBTelehealth, Winnipeg Regional Health Authority where she ahs been involved with the development of the MBTelehealth Network since its inception in 2001. Prior to this position, she was involved in developing research capacity in both academic and practice environments particularly related to outcomes measurement, community nursing practice, and health information systems. She has practiced as a Registered Nurse in both acute care and community-based settings. Current projects include developing a balanced scorecard framework to evaluate telehealth programs, development of a real-time urgent/emergent link to support neonatal care, evaluation of the effectiveness of teaching using interactive videoconferencing, and implementation of digital stethoscopes as well as the development of numerous specialty services on the telehealth network.

Sarah Muttitt, MD, FRCPC, FAAP, MBA
Director, MBTelehealth
Dr. Sarah Muttitt assumed the position of Director, MBTelehealth, in September 2003. She has more than twenty years experience in the healthcare industry with a clinical background in pediatrics and neonatology and private sector experience in the development and implementation of innovative healthcare technologies. A University of Alberta medical school graduate, she holds subspecialty certification in both Canada and the US, and completed her MBA from the Ivey Business School at the University of Western Ontario in 1999. Dr. Muttitt has been active in telehealth since 1998 when she joined TecKnowledge Healthcare Systems, establishing their Western Canadian regional sales and project office. Since that time, Dr. Muttitt has applied her skills to the planning and implementation of more than a dozen telehealth programs across Canada and the US. In addition, she has contributed to many strategic industry events including the National Telehealth Interoperability Workshop and Health Canada's Telehealth Sustainability Workshop.

Introduction: The MBTelehealth Network serves 21 communities in Manitoba and routinely links to both Northwestern Ontario and Nunavut for patient care services. The network was established in 2001 as a CHIPP funded project and has since obtained sustained funding for ongoing operations. The Network has continued to see considerable growth with network utilization increasing to an average of 264 sessions per month in the first half of the 2003/04 Fiscal Year from 170 sessions per month in 2002/03. The proportion of clinical activity has also increased to 69.7% from 52.6% of all sessions during the same time. The network underwent an external evaluation of its operations during CHIPP however; the shift to sustained programming has highlighted the need for an ongoing internal evaluation process to support informed network operations and accountability. The network is now focused on the development of a Balanced Scorecard approach to evaluating ongoing network operations.

Description: The Balanced Scorecard, developed by Kaplan and Norton in 1996, provides a framework for translating organizational goals into performance measures from multiple perspectives. Used initially in for-profit settings, this approach has been adopted more recently in health care settings. Preliminary indicators have been developed for MBTelehealth that relate to the four quadrants utilized by the CCHSA's AIM Measures of system competency, client/community focus, responsiveness, and work life. Network and site-specific indicators were developed and validated through consultation with local site coordinators and regional partners. Reporting on indicators and targets is now included in existing ongoing communication with MBTelehealth's partner organizations and are utilized to regularly review and adjust network operations overall and at a site-specific level.

Results: This presentation will focus on the process for development of the MBTelehealth Balanced Scorecard and will include indicators and benchmarks identified to date as well as adjustments made to reflect evolving network priorities.

The Veterans Health Administration (VHA) has developed and implemented an innovative health care delivery model called Care Coordination/Home Telehealth (CCTH) which has expanded the patient and provider relationship into the home. CCTH can be defined as the ongoing monitoring and assessment of selected patients, usually those with chronic diseases, using home telehealth technologies to improve health status, increase the effectiveness of care and decrease resource utilization. This patient centric model uses Care Coordinators to coordinate services across the VHA continuum of care through collaboration with all providers and accessing needed resources and entitlements. This model is designed to fill in the gaps so there is no "falling through the cracks".

In April 2002, the President's New Freedom Commission on Mental Health was formed to address the problems in mental health service delivery including fragmentation of services. As a result of the Commission Report, the Under Secretary for Health of the VHA charged a work group to develop an Action Agenda "Achieving the Promise: Transforming Mental Health Care in VA". Based on the high rates of physical disorders, side effects of atypical psychotropic medications and unhealthy lifestyles, this document called for innovative collaborative care models to coordinate chronic health care for veterans with serious mental illness. CCTH is such a health care delivery model.

Although in early developmental stages, various CCTH models for veterans with serious mental illness will be described and lessons learned from efforts to transform mental health care using a health care delivery model with home telehealth technologies will be discussed. Implications for program evaluation via a CCTH Registry and research opportunities will also be highlighted.

At the Alaska Veterans Healthcare System and Regional Office (AVHSRO) there is one Radiologist on site. Our objective is to use technology to provide improved access to care. The AVAHSRO has chosen to leverage national VA talent and resources to supplement radiology services to local area veterans. We have over 15 months experience in routing digital X-rays through our secure Local Area Network to a remote VA Radiologist. This physician has extensive experience with teleradiology, routinely conducting remote reads from her home for a network of Veteran Administration Medical Centers throughout the Midwest. She has read 313 cases for us when our local Radiologist has been unavailable. In addition, for the past 6 months, she has averaged reading 90 cases/quarter for peer review.

The steps in the cycle are noted below and are detailed in the poster. The one additional step in securing remote teleradiology support is noted with an *:

1. Anchorage radiology department obtains the X-ray images with digital equipment
2. Anchorage radiology department "flips the switch" to route the digital images to remote Radiologist over the secure VA Local Area Network
3. Radiologist views and interprets the X-rays from workstation
4. Radiologist phones transcription services and dictates the report
5. Radiologist is electronically notified when the report is ready for verification
6. Radiologist electronically signs and verifies the report
7. Images and report are instantly retrievable within the patients record

This presentation will outline the theoretical steps to build a statewide system, describe what has already been accomplished to achieve a statewide system and the work left yet to do. It will describe policy, technical, and program issues.

The Alaska Telehealth Advisory Council since it beginning in 1999 has reviewed and acted upon the broad issues involved with Telemedicine in our State and could form the basis of a polity group. The AFHCAN project has developed major pieces of infrastructure for the federal sector. This presentation will explore the missing pieces and hurdles to expanding the system statewide.

Matvey Nikolaev was born February 6th, 1967 in Yakutsk, Sakha Republic, Russia. He graduated from the Medical and Biological Faculty at Tomsk Medical Institute in 1994 with major in medicine and biophysics. In the period between 1994 and 1999 he worked as doctor at the Sakha Clinical & Diagnostic Center, National Center for Telemedicine of the Sakha Ministry for Health Care. In 1998, Dr. Nikolaev entered a postgraduate school of the Russian Medicine Academy, Russian Ministry for Health Care. He took active participation in Russian and international conferences on innovation issues in health care and telemedicine development in Russia.

Dr. Nikolaev was appointed Director of the Telemedicine Centre at the Sakha National Center in March 2000. For the period of 2000-2002, the Sakha Telemedicine Center has arranged telemedicine consultations for 205 patients including 58 children. In total the Center has provided videolectures for 1,000 doctors and 67 lectures have been given by professors and academicians from leading Russian medical institutions. The Telemedicine Center has also held 15 international research conferences with colleagues from 11 cities in Europe, the United States and Australia.

In December the same year Matvey Nikolaev joined the Telemedicine Coordination Council of the Russian Ministry for Health Care. Dr. Nikolaev was awarded a Diploma of the Sakha Ministry for Health Care in 2001 for his great contribution to the development of medicine technologies in health care in Sakha Republic. In February 2003, Matvey Nikolaev was granted a scientific degree of the Candidate of Medical Sciences at the Dissertation Council of the Central Research Institute for Health Care Organization and Informatization, Russian Ministry for Health Care. His dissertation examines scientific and organizational aspects of telemedicine implementation in health system management in Sakha Republic. Dr. Nikolaev chairs the association of young doctors in Yakutsk that was established in 1999. Matvey Nikolaev has a wife and a 10-year daughter.

The concept and program for the united information system in the health care sector in Sakha, developed in cooperation with colleagues, resulted from organizational work and research carried out by the author who is the Chair of the Sakha Ministry for Health Working Group on Telemedicine and a member of the Russian Telemedicine Council. At the present stage 3 program phases were implemented:

1. An email system for all medical and preventive institutions in Sakha and 32 local hospitals was established.
2. The Telemedicine Centre at the Sakha Centre for Telemedicine was established and it connected eight cities and rural medical institutions with a telemedicine video network.
3. The clinical information system Interin is being introduced as a pilot program.

All in all 205 telemedicine consultations were held, 67 video-lectures for local doctors were conducted by professors from leading research medical institutions in Moscow. So, the Sakha Telemedicine Centre is gaining experience, it also conducts research with their colleagues from Russia, European, American and Australian centers.

We plan to expand the telemedicine network to include remote communities; however there are some obstacles toward planned introduction of telemedicine in the health care system. These include: a lack of funding to support the program for the telemedicine network in the health care sector; untrained specialists in telemedicine technology; and a lack of the legislative and legal basis for telemedicine as a medical activity.

Presently new research methods for the sustainable development of telemedicine in Sakha are being developed at the Sakha Science Center, Russian Academy of Medical Sciences.

Introduction: Telemedicine now has a major role in the treatment of patients with minor injuries in Northeast Scotland. We have developed a network linking 14 minor injury units, allowing easier access to health care and specialist follow up. Initial management can be safely and reliably delivered at a distance. The aim of this study is to show that review consultations can be conducted as safely. We have already published data from a 1-month period on this subject.

Methods: Having set up a videoconferencing network using ISDN 6 to link all sites we then created a review fracture clinic. Consultation details were recorded and then entered into a dedicated database. The study period was September 2001 to August 2003. Patients who required surgery (other than manipulation of fractures) were not reviewed by telemedicine.

Results : There were a total of 3042 consultations, of which 1222 were for review. Initial assessment was by telemedicine or presentation to the Accident & Emergency Department in Aberdeen. There were 999 consultations regarding fractures. The other 223 related to soft tissue injuries or wounds. Orthopedic injuries typically require more than 1 review appointment. The mean number of reviews was 2.75 per patient. There were no adverse events as a result of using a videoconferencing system.

Discussion: We have found that using videoconferencing to follow up minor orthopedic trauma is a safe and reliable way supplying remote health care. Medical and Nursing staff in the minor injury units were satisfied with the service, as were patients as it prevented multiple journeys to Aberdeen. The next step is to recruit patients who have required orthopedic surgery to the clinic. This network could also be used by other specialties.
(References: 1. Palombo A, Ferguson J, Rowlands A, Pedley D, Fraser S. An evaluation of a telemedicine fracture review clinic. J Telemed Telecare. 2003;9 Suppl 1:S31-3.)

Chris Patricoski M.D. is clinical director for the Alaska Federal Health Care Access Network (AFHCAN) in Anchorage, Alaska. Dr. Patricoski brings 10 years of clinical experience as a family physician to the AFHCAN team. He guides medical applications and maintains clinical focus to the overall mission. He has had key roles in product development, assessment, education and research.

Dr. Patricoski is a graduate of West Virginia University School of Medicine, where he completed his residency in Family Medicine. Dr. Patricoski served as the rural curriculum coordinator for WVU Department of Family Medicine while practicing at Camden-on-Gauley Medical Center in Webster County, WV. He relocated to Alaska in 1998, where he worked at Providence Seward Medical Center in Seward, Alaska, at the tip of Resurrection Bay, the Gateway to Kenai Fjords. In February 2000, he joined the Alaska Federal Health Care Access Network, Alaska's largest telemedicine program with deployments at 248 sites. Dr. Patricoski has worked short term in many other settings providing care to underserved areas. He has received a number of community service and leadership awards. He has published a variety of peer reviewed articles and has presented at national meetings. Dr. Patricoski is a Board Certified Family Physician promoting the importance of quality care, technology, and continuing education in the rural practice settings.

Introduction: Native American children are particularly prone to middle ear disease; many require tympanostomy tube placement. In fact, myringotomy and tube placement is the most commonly performed pediatric procedure/surgery in the United States. Perhaps one could use a picture of an ear drum and ear tube to follow up on the children living in remote areas. This study was conducted to determine if video otoscope still images (640 x 480 pixel resolution) of the tympanic membrane following surgical placement of tympanostomy tubes are comparable to an in-person microscopic examination.

Materials & Methods: Eighty ears from forty patients having undergone tympanostomy tube placement were independently examined in-person by two otolaryngologists and imaged using a video otoscope and telemedicine software package. The two physicians later reviewed images at 6 and 12 weeks. Physical examination findings and diagnosis were documented and compared for their concordance using kappa statistics.

Results: For both physicians, the intraprovider concordance between the in-person examination and the corresponding image review was high for each of the physical examination findings: Tube In 93 - 94% (K 0.85-0.87), Tube Patent 86 - 93% (K0.74-0.85), Drainage 94 - 98% (K0.42-0.66), Perforation 85 - 98% (K 0.40-0.84), Granulation 95 - 99% (K -0.01-0.00), Middle Ear Fluid 89 - 91% (K -0.03-0.50), and Retracted 89 - 94% (K 0.13-0.43). These agreement rates are similar to the normal interprovider concordance observed when two physicians independently examined the same patient in-person for physical exam findings: Tube In 96% (K 0.93), Tube Patent 94% (K 0.88), Drainage 96% (K 0.56), Perforation 90% (K 0.60), Granulation 96% (K 0.39), Middle Ear Fluid 88% (K 0.14), and Retracted 91% (K0.43).

For both physicians, the intraprovider diagnostic concordance between the in-person examination and the corresponding image review was high 79 - 85% (K 0.67-0.76). The interprovider diagnostic concordance for the in-person exam was 88% (K 0.81). The interprovider diagnostic concordance when two physicians independently reviewed all images was 84% (K 0.74), and 89% (K 0.80) when poor images were excluded.

Conclusions: Video otoscope still images of the tympanic membrane are comparable to an in-person microscopic examination. Store-and-forward telemedicine using a video otoscope may be an acceptable method of following patients post-tympanostomy tube placement.

Chris Patricoski M.D. is clinical director for the Alaska Federal Health Care Access Network (AFHCAN) in Anchorage, Alaska. Dr. Patricoski brings 10 years of clinical experience as a family physician to the AFHCAN team. He guides medical applications and maintains clinical focus to the overall mission. He has had key roles in product development, assessment, education and research.

Dr. Patricoski is a graduate of West Virginia University School of Medicine, where he completed his residency in Family Medicine. Dr. Patricoski served as the rural curriculum coordinator for WVU Department of Family Medicine while practicing at Camden-on-Gauley Medical Center in Webster County, WV. He relocated to Alaska in 1998, where he worked at Providence Seward Medical Center in Seward, Alaska, at the tip of Resurrection Bay, the Gateway to Kenai Fjords. In February 2000, he joined the Alaska Federal Health Care Access Network, Alaska's largest telemedicine program with deployments at 248 sites. Dr. Patricoski has worked short term in many other settings providing care to underserved areas. He has received a number of community service and leadership awards. He has published a variety of peer reviewed articles and has presented at national meetings. Dr. Patricoski is a Board Certified Family Physician promoting the importance of quality care, technology, and continuing education in the rural practice settings.

Store-and-forward (S&F) telemedicine is the asynchronous transmission of patient information over a distance to provide patient care. In addition to demographics and patient notes, S&F telemedicine usually includes an image or data set necessary for diagnosis and/or management of the patient. Radiology and dermatology commonly utilize the S&F modality. A committee of clinicians and educators within Alaska decided in 1998 that S&F telemedicine should be the chief mechanism of teleconsultation within the Alaska federal health care system. This was chosen because S&F allows the consultant to respond during an available time slot. In addition, most primary care referrals do not require immediate intervention with real time telemedicine. S&F requires less technical support at the initiating end; however, it requires a reliable software package and associated peripheral hardware.

In Alaska, clinicians have shown that S&F telemedicine is an efficient means of expanding and enhancing health care delivery. S&F telemedicine is especially useful in supporting and providing primary care / frontier medicine. Remote and regional clinicians believe that S&F telemedicine increases access to care and improves quality of care. A successful S&F telemedicine program requires appropriate technologies and commitment from technical and clinical staff. Initial reports indicate that there are substantial cost savings in travel when using S&F telemedicine in Alaska.

In addition, the AFHCAN telemedicine software and hardware has produced collateral benefits. The software allows for patient education using the display of images. Clinicians report increased patient satisfaction when there is visual reinforcement of the clinician's explanation. There also seems to be some provider education happening with the consulting physician explaining lesions, treatment options, etc. to the initiating provider. Overall, providers who initiate consultations feel the system makes their jobs "more fun." Finally, there is a noted benefit from using the S&F software as an image repository to create a multimedia record of patient encounters.

Chris Patricoski M.D. is clinical director for the Alaska Federal Health Care Access Network (AFHCAN) in Anchorage, Alaska. Dr. Patricoski brings 10 years of clinical experience as a family physician to the AFHCAN team. He guides medical applications and maintains clinical focus to the overall mission. He has had key roles in product development, assessment, education and research.

Dr. Patricoski is a graduate of West Virginia University School of Medicine, where he completed his residency in Family Medicine. Dr. Patricoski served as the rural curriculum coordinator for WVU Department of Family Medicine while practicing at Camden-on-Gauley Medical Center in Webster County, WV. He relocated to Alaska in 1998, where he worked at Providence Seward Medical Center in Seward, Alaska, at the tip of Resurrection Bay, the Gateway to Kenai Fjords. In February 2000, he joined the Alaska Federal Health Care Access Network, Alaska's largest telemedicine program with deployments at 248 sites. Dr. Patricoski has worked short term in many other settings providing care to underserved areas. He has received a number of community service and leadership awards. He has published a variety of peer reviewed articles and has presented at national meetings. Dr. Patricoski is a Board Certified Family Physician promoting the importance of quality care, technology, and continuing education in the rural practice settings.

Introduction: In Alaska approximately 250 sites are using the AMD/Welch Allyn video otoscope and AFHCAN Telemedicine Software. Over 3500 ear images have been acquired by community health aide practitioners, audiologists, and physicians. The video otoscope needs to be focused prior to ear insertion. Once the tip is in the auditory canal, it is difficult, dangerous, and painful to manipulate the focus ring. Observations from training indicate that users have difficulty prefocusing the tool as it is inaccurate to judge the proper distance and it is difficult to hold the probe tip steadily. We, therefore, set out to develop a focus tool to assist with proper focus.

Methods: An important step in building a focus tool is to establish the correct distance from the video otoscope tip at which to focus an object.

1. The theoretical distance was established by focusing the video otoscope on a 1.0 cm circle at various distances.
2. The distance was determined with geometric calculations (10mm/tan 38 degrees).
3. Finally, the above was confirmed with imaging two adult ears.

Results: To utilize the focus tool one turns on the power to the illumination platform, presses "Image Enhance" and cleans the video otoscope tip with alcohol. The focus tool is then slid over the tip of the scope until the focus tool abuts the T connecter. At that point, the tip of the scope is 11 mm from the black mesh serving as the focus target. One holds the focus tool and otoscope in place while turning the focus ring until the black mesh appears in focus. Feedback has been positive regarding this new device.

Conclusion: The focus tool is accurate and the plastic casing simulates the shape of the ear canal. It is safe in that it will not scratch the instrument. Several hundred focus tools have been produced for immediate distribution throughout the state. The device is helping to sharpen tympanic membrane images. The focus tool is proving to be an important adjunct for quality imaging with the video otoscope.

Frederick W. Pearce, Ph.D. is a Professor of Telecommunications, Director of the Applied Sciences Laboratory, and Chair of the Department of Journalism and Public Communication at the University of Alaska Anchorage.

Dr. Pearce has an extensive background in broadband telecommunications and information technologies. He has worked in the television industry and developed applications and content for distributed learning systems. Since 1994, he has been developing, deploying, and evaluating narrow bandwidth telemedicine and telehealth applications and technologies for Alaska, rural America, and the emerging world.

Dr. Pearce was the Director of the Alaska Telemedicine Project (1994-2000) and Principle Investigator of the "Alaska Telemedicine Testbed Project" (1996-2001) funded by the National Library of Medicine. Dr. Pearce developed the "Alaska Telehealth System" used for remote clinical decision support, and the "Alaska Telemedine Workstation," which is being used to deliver clinical medical support throughout Alaska and the Russian Far East. Dr. Pearce is currently the Principal Investigator of the "Alaska Medical Informatics Initiative" (AMII). Funded by the Department of Defense, AMII is a set of "internet medical tools" designed for emergency medical evacuations and clinical decisions support for rural and frontier healthcare in the "digital age." Dr. Pearce is a graduate of Iona College. He holds his Ph.D. from the University of Pittsburgh.

The Alaska Telemedicine Testbed Project was a five-year study funded by the National Library of Medicine in 1996 to demonstrate and evaluate the use of narrow bandwidth telemedicine for otolaryngology (ENT) in 33 remote Alaska villages and towns, four regional centers, and Anchorage. Telemedicine workstations and software were developed and deployed. Training and support systems were developed.

The evaluation of narrow bandwidth ENT was designed to look at patient and provider "satisfaction;" to determine if healthcare informatics could increase the "survival" of healthcare providers in frontier Alaska; and to determine costs and benefits of telemedicine for ENT in frontier Alaska.

Project results suggest that telemedicine for ENT was perceived by frontier patients and providers "as good or better than" current transportation-based models for ENT services in frontier Alaska (n = 10,005). The use of healthcare informatics to reduce professional isolation and increase "survival" for healthcare professionals in frontier Alaska was inconclusive due to the length of the study (n = 998).

Costs of telemedicine ENT encounters during the project ranged from $281 per encounter to $137 per encounter (n = 3,957). Frontier patients perceived a benefit (perceived decrease of "provisioned service" or an increase in perceived "value") of $25 per ENT encounter (n = 497). In addition, unexpected results indicated that the use of telemedicine for ENT reduced the use of antibiotics in treatment of ottis media by up to 5% (n = 2,555). Finally, a qualitative study designed to reveal Community Health Aid "feelings and thoughts" regarding project indicated that frontier practitioners were overwhelmingly positive with the system processes, training, and support (n = 18).

Karen Perdue is the Associate Vice-President for Health at the University of Alaska. She was appointed to this position in October of 2001 by the President of the University to help develop health and social sciences capacity throughout the University. Ms. Perdue has 23 years of experience in health and human service issues in Alaska.

From 1994 to 2001, Ms. Perdue served as the State's Commissioner of Health and Social Services, overseeing 2,200 employees and a budget of $1.2 billion. She was the longest serving DHSS Commissioner since statehood. During her tenure, she led the state's efforts in welfare reform, the development of Denali Kidcare and Smart Start, comprehensive initiatives in primary care and fetal alcohol syndrome and many other initiatives. As Commissioner, she also directed the state's public health, child welfare, Medicaid and public assistance programs, juvenile corrections, substance abuse and mental health departments.

She serves on the steering board of the National Center for Excellence on FAS, the State FAS Steering Committee, the State's Suicide Prevention Council, the Alaska Telemedicine Advisory Council and many other boards. She serves as the US Representative on Sustainable Development for the Arctic Council, an eight-member arctic nation forum.

A life-long Alaskan, Ms. Perdue has been a Teamster on the Trans-Alaska oil pipeline, a health planner, a business owner, a newspaper reporter, an aide and press secretary to US Senator Ted Stevens, and served in numerous positions in State government. She is a graduate of Stanford University with a major in biology.

She is the recipient of numerous awards including the Alaska Public Health Association Award, the Dot Truran Advocate Award for Persons with Disabilities, the YWCA Woman of Distinction, the Friend of EMS award, the National Association of Social Workers Award and many others. She is an honorary public health nurse, and in 2000 was named by the Alaska Journal of Commerce as one of 25 most powerful Alaskans.

Introduction: As telehealth and telemedicine quickly become part of mainstream healthcare, specific program marketing and evaluation tools become a necessity for long-term development and sustainability of telehealth networks. This presentation will highlight how MBTelehealth has developed a simple "Marketing Plan" template that is easily applicable to all of its sites in 21 communities across the province of Manitoba.

Methods: In collaboration with management, local site coordinators assess their specific area markets and develop marketing strategies which best address needs in areas of patient clinical services, education development for health care providers and community support groups, as well as time for administration and management meetings. Overall marketing objectives are then integrated into site-specific balanced scoreboard evaluation strategies.

Results: Through linking marketing to balanced scorecard measurements, potential growth and development areas of the program are easily identified and marketing plans are revised accordingly. Having marketing templates already in place and tied to evaluation efforts is critical as the network looks at possible expansion in the 2004-2005 fiscal year with 5 new rural sites and up to 7 urban sites proposed.

Discussion: This presentation will highlight the marketing plan template, describe barriers to marketing and network utilization as well as discuss innovative approaches developed in response to site specific issues such as local physician buy-in, provider accessibility and local site coordinator time management.

Dr. Puskin is the Director of the Federal Office for the Advancement of Telehealth. Prior to her current position, Dr. Puskin served as the Acting Director of the Federal Office of Rural Health Policy (ORHP). Dr. Puskin has assumed many leadership positions within and outside of government. Prior to joining ORHP in 1988, Dr. Puskin was a senior analyst at Congress's Prospective Payment Assessment Commission, where she developed the model for annual updates of Medicare payment rates to hospitals and worked on numerous economic issues related to rural hospitals and specialized hospitals in the U.S. (psychiatric, rehabilitation, and chronic disease hospitals). From 1982-1988, she was employed by the Blue Cross/Blue Shield Association as a senior legislative analyst in Washington D.C. Dr. Puskin served as the Research Director at the Finger Lakes Health Systems Agency and as Assistant Professor of Community Medicine at the University of Rochester School of Medicine and Dentistry from 1977-1981.

Dr. Puskin currently chairs the Joint Working Group on Telemedicine, the Federal interagency committee coordinating the development of telemedicine initiatives across the Federal government, and within the Department of Health and Human Services. Dr. Puskin spends considerable time speaking at national forums and writing academic papers and reports on telehealth, rural health, and health care financing issues. In the past year, she has given over 20 speeches and published numerous papers on telehealth.

Dr. Puskin received her Sc.D. degree in Health Policy and Research from Johns Hopkins University, a M.S. degree in Community Medicine from the University of Rochester, School of Medicine and Dentistry, and B.A. and M.A. degrees in Biology from Boston University.

New technologies, such as interactive voice response (IVR) systems and videophones, provide new options for home-based mental health care for individuals with severe mental illness (SMI). There is a strong history of home-based care for this population. One of the most successful services for preventing hospitalization in individuals with SMI is Assertive Community Treatment (ACT; Mueser, Drake, Bond, & Resnick, 1998), in which a team of clinicians provide frequent community-based visits to their clients. However, because VA is a regional system, geographic barriers limit these kinds of intensive face-to-face services. Also, some veterans with SMI who do not need intensive services such as ACT, but for whom hospital-based care is appropriate, have limited transportation resources, and are unable to keep their appointments due to travel limitations.

We are currently in the process of developing two home-based interventions to enhance care for veterans with SMI with geographic or transportation barriers: an IVR system to help identify those at risk for missing aftercare appointments following discharge from a psychiatric inpatient unit, and a videophone case management/treatment adherence intervention for people with SMI.

We will present preliminary data on geographic and transportation barriers to aftercare services from a survey of veterans with SMI being discharged from a psychiatric inpatient unit that will allow us to identify candidates for home-based telemental health, and patient interest and use of IVR. We will also present descriptive data on service delivery to a set of pilot videophone cases who have completed treatment at the time of the conference (6 cases as of 11/03). Finally, we will present qualitative data on both patient and provider response to the use of telemedicine for home based mental health treatment.

(Mueser, K. T., Drake, R. E., Bond, G. R., & Resnick, S. G. (1998). Models of community care for severe mental illness: A review of research on case management. Schizophrenia Bulletin, 24, 37-74.)

There are members of our society who pay a penalty for living in remote communities. Native Americans and Alaskan Natives are particularly disadvantaged. Among the most significant disadvantages are limitations in access to healthcare services and education. Telemedicine offers hope in addressing these inequities. Telemedicine can reduce the impact of distance by using information and communications technologies to move medical information across rather than moving patients or providers.

University of North Dakota School of Medicine & Health Sciences established a center to extend access to healthcare and to enhance healthcare services by applying telemedical technologies. The Health Information Technology (HIT) Center has received core funding from a GSA program to support and assist rural Americans. The overall goals of the HIT Center are achieved through a number of specific telemedicine projects. Healthcare delivery projects of the HIT Center are undertaken based upon local assessment of patient and provider needs as well as the potential of telemedicine technology to address them.

The HIT Center has inaugurated first of its kind secure video conferencing connection between the Social Security Administration office in Minot, ND and Quentin Burdick Medical Center on the Turtle Mountain Reservation in Belcourt, ND. This capability will make if more convenient and less time consuming for patients to provide their medical history to SSA representatives who are determining their eligibility for disability benefits. Early reaction to the service is very positive. Applications are up nine fold and applicants prefer the service over past communications methods. An evaluation is underway to determine other short term and longer term effects.

At a time when health system and local budgets are stretched, telemedicine projects through the HIT Center can represent the sole avenue to technological progress in healthcare delivery and education in rural, remote communities.

There are members of our society who pay a penalty for living in remote communities. Native Americans and Alaskan Natives are particularly disadvantaged. Among the most significant disadvantages are limitations in access to healthcare services and education. Telemedicine offers hope in addressing these inequities. Telemedicine can reduce the impact of distance by using information and communications technologies to move medical information across rather than moving patients or providers.

University of North Dakota School of Medicine & Health Sciences established a center to extend access to healthcare and to enhance healthcare services by applying telemedical technologies. The Health Information Technology (HIT) Center has received core funding from a GSA program to support and assist rural Americans. The overall goals of the HIT Center are achieved through a number of specific telemedicine projects. Healthcare delivery projects of the HIT Center are undertaken based upon local assessment of patient and provider needs as well as the potential of telemedicine technology to address them.

The most ambitious project placed a local capability to do specialized diabetes eye examinations. High resolution images of the retinas will be taken at the Quentin Burdick Medical Center on the Turtle Mountain Reservation in Belcourt, ND to detect early retinal damage from diabetes and potential threats to vision. Images are stored in a secure server and then transmitted to Retina Consultants in Fargo, ND for reading and consultation by specially trained ophthalmologists. This new capability will increase patient compliance, eliminate patient travel requirements, improve medical outcomes, and reduce healthcare costs. Already the presence of the camera and server means that no patients have to return for re-imaging. Additionally the images which would have previously resided in a specialists office are in the hospital on the reservation. Other effects including time, cost, convenience, and confidence will be measured.

There are members of our society who pay a penalty for living in remote communities. Native Americans and Alaskan Natives are particularly disadvantaged. Among the most significant disadvantages are limitations in access to healthcare services and education. Telemedicine offers hope in addressing these inequities. Telemedicine can reduce the impact of distance by using information and communications technologies to move medical information across rather than moving patients or providers.

University of North Dakota School of Medicine & Health Sciences established a center to extend access to healthcare and to enhance healthcare services by applying telemedical technologies. The Health Information Technology (HIT) Center has received core funding from a GSA program to support and assist rural Americans. The overall goals of the HIT Center are achieved through a number of specific telemedicine projects. Healthcare delivery projects of the HIT Center are undertaken based upon local assessment of patient and provider needs as well as the potential of telemedicine technology to address them.

The first healthcare education project of the Center was to enhance the clinical skills of students in medicine and the health sciences through the introduction of telemedicine technology to clinical teaching. The challenge of teaching the eye exam is being met with a video ophthalmoscope. Faculty demonstrations are first projected in high resolution for the whole medical student class to see and then in sequence students performances are viewed by all and critiqued by faculty. A preliminary evaluation shows a student preference for the technique but data on the change in skill levels caused by the approach is still forthcoming.

This presentation will outline the development of telehealth services in Alaska, including the early use of single-side band radios for medical consultation services, the 1970's experimental NASA ATS-1 and ATS-6 satellites, and deployment of a statewide satellite-based telecommunications system by the State of Alaska. Later developments include the organization of an inter-agency coordination effort by the University of Alaska, a pilot project using store and forward technologies in several western Alaska regions funded by the National Library of Medicine, and the creation of the Alaska Federal Health Care Access Network.

The presentation will also briefly summarize the work of the Alaska Telehealth Advisory Council and the various projects it has supported since 1999, and current plans for deployment of telehealth capacity to a wider array of medical providers serving the Alaska community.

The Alaska Federal Health Care Partnership (AFHCP) Teleradiology project is a Multiyear project to implement Teleradiology and PACS to 55 sites. The project began in 1997 deploying PACS and Teleradiology to the four tertiary care facilities. The next deployment phase was in 1999 to the 11 regional hospitals and clinics bi-directional functionality via workstations, digitizers and frame grabbers. The next began in 2000 with the deployment of Computed Radiography (CR) to village clinics. In 2002/03 there was a reassessment of the implementation to include PACS infrastructure to regional Hospitals. The current 2004 deployment focuses on bringing all regional Hospitals to a fully implemented PACS.

Teleradiology greatly increased the turn around times for diagnostic interpretations from 9 to 21 days to within 24 hours and immediate response on emergencies. Village Clinic imaging is typically performed by Midlevels, CHAPs and even clerical staff. The implementation of CR and training focusing on taking X-rays for the non-Radiology Technologist has improved image quality for the Radiologist.

The presentation is an overview of the status of Teleradiology in Alaska and the future of the project. It focuses on experiences, successes and lessons learned from deployment, equipment utilization, connectivity issues, equipment cost verses the quality of service and methods invoked to meet diagnostic interpretation requirements in Alaska.

Eugene S. Smith, a life-long resident of Kotzebue, began working for Maniilaq in November 1994. Initially hired in the maintenance department, Eugene quickly joined Maniilaq's information technology staff and now serves as our corporation's Chief Information Officer.

With Eugene's leadership, the Maniilaq Information Services Department has developed many innovative and successful programs. One such program, initiated in 1997, offers talented students an opportunity to work for the department during school vacations. Both high school and college students are now a part of the department, returning each summer to assist with many summer projects.

Other successful efforts include the Inutek.net consortium, a joint-venture between Maniilaq, OTZ Telephone, and GCI. The consortium offers high speed internet access to all of NW Alaska at rates comparable to those in urban areas. The demand for services has exceeded expectations, allowing Maniilaq to hire information technology personnel in eight villages. The consortium has relied on local resources and a tradition of cooperation to bridge the digital divide for residents throughout the region.

Maniilaq Information Services is also a nation-wide leader in telemedicine delivery. The department utilizes high bandwidth network connection in every village to deploy services such as electronic medical records, video conferencing, and remote imaging. Eugene's experience and expertise are frequently requested at statewide telehealth conferences.

Eugene and his staff are currently working on many new and exciting projects to improve infrastructure and services throughout the Maniilaq service area.

In the past seven years Maniilaq Health Center has become a leader in using technology to provide healthcare in remote Alaska. This hospital, located in Kotzebue, Alaska, has broadband connectivity to its surrounding 12 village health clinics. Connectivity is used for real time videoconferencing between community health aides in the village clinics and physicians at Maniilaq Health Center in Kotzebue. Videoconferencing has also been used for crisis counseling, educational and administrative purposes. The health center has a high volume of store-and-forward telemedicine cases using the AFHCAN telemedicine software. In addition, Teleradiology has begun for medical and dental applications.

The success of Maniilaq Health Center is attributable to many factors. First, the leaders have conviction that technology can and should be used to improve health care. Second, there is a conscious effort to engage as many stakeholders as possible. This teamwork concept leads to a coalition of technicians, doctors, administrators, community health aide practitioners and biomedical support staff. Third, there is a willingness to adopt new technologies and strategies. For example, the move to wireless provided a lot of opportunity for trial and error using radio, laser, microwave, etc. The team stayed with the concept and got it right. Fourth, training is a priority. All IS employees are expected to constantly expand their skill set in addition to improving within their specialty, such that each will be able to act independently in the villages. Cross training is essential so that there is a common skill set among the technicians. Types of skills include network administration, desktop support, and even manual labor such as pouring concrete foundations and installing external antennas. With long distances and increasing travel costs, it is essential that the technicians have a wide breadth of knowledge to deal with a variety of scenarios. Fifth, standardization is implemented where possible. Once a stable solution is discovered, it is important to standardize the technology whether it is hardware (wireless gear, video conferencing equipment, personal computers, and network routers) or software (Microsoft products and AFHCAN telemedicine software). Standardization complements flexibility by controlling complexity and costs. Therefore, more human and financial resources can be spent on breaking new ground.

Introduction: Although a considerable amount of research has examined the physician-patient relationship in terms of communication variables and processes, little research has focused on communication during pediatric consultations. Another area that this research has not focused much on - due to its relative novelty in the healthcare arena - is telemedicine. This study builds on past research involving telemedicine technology and how it affects the physician-patient relationship during pediatric visits by examining parents' communication satisfaction with their child's physician in two contexts: 1) a face-to-face setting and 2) a telemedicine setting.

Methods: The 26-item Parent Medical Interview Satisfaction Scale (P-MISS) was administered to parents in both settings to determine whether their communication satisfaction differed between the two contexts. One hundred ninety-six surveys were collected; 98 surveys were collected in each setting. Surveys were administered from September 2002 through mid-April 2003 to parents of children who visited a physician, either face-to-face or via a school-based telemedicine project called TeleKidcareŽ, for acute medical concerns.

Results: Survey data is currently being analyzed to determine if significant differences in parents' communication satisfaction with physicians exist between the two methods of delivery. Preliminary analyses suggest that parents are more satisfied with their communication with their child's physician during telemedicine consults.

Discussion: While this study does not attempt to examine every aspect of the physician-patient relationship across two communication media, it begins to address the salient issue of communication satisfaction. Although it is important to investigate parents' general satisfaction with telemedicine consultations, there is more utility in being able to compare those perceptions with perceptions from face-to-face consultations. In addition to obtaining information about parents' satisfaction with school-based telemedicine, this study compares those findings with information obtained in the same manner about parents' satisfaction with traditional pediatric office visits.

The University of Kansas Medical Center (KUMC) began providing cancer care via telemedicine eight years ago. The project connected a KUMC oncologist with a rural medical center 265 miles away in 1995. After establishing the initial clinic in Hays, another telemedicine clinic was developed in 1997 in Horton, Kansas, approximately 90 miles from KUMC. A team of professionals including the KUMC oncologist, on-site nurses, administrative personnel, and technical support staff collaborates to provide periodic on-site services in addition to the services provided telemedically. Utilizing telemedicine technology, patients with cancer in areas without oncologists are able to receive treatment regularly in their home communities.

To date, there are few studies reporting expenses associated with providing telemedicine services for rural areas. A 1998 study-conducted to determine the average cost per consult when providing tele-oncology services-revealed an average cost of just over $800 per telemedicine visit. The goal of the analysis reported herein was to document expenses associated with tele-oncology visits for fiscal year 2000. Data from this recent analysis indicate an average cost of $410 per consult in Hays and $629 per consult in Horton. With the oncologist managing patient care from a distance, fees generated from chemotherapy administration, ancillary services, and diagnostic radiology remain within the local health care systems in Hays and Horton, helping to offset the expenses related to telemedicine practice. The tele-oncology practice continues in both communities because it provides a valuable service enabling patients with cancer to receive care close to home, and because it is economically sound. Additional details of the Kansas tele-oncology project including ongoing cost analyses will be discussed.

The Highlands and Islands Teledentistry project provided specialist support in restorative dentistry to rural and island general dental practitioners in the Highlands and Islands of Scotland. The paper provides an overview of the research, summarizes the findings and highlights the lessons and problems identified in establishing this innovative teledentistry pilot service.

The project accomplished the following tasks:

• Determined imaging needs and solutions for teledental restorative dental consultations and evaluated and selected equipment and software for live videoconference consultations.
• Established the setting in the Dental Department Aberdeen for trial teledentistry consultations and evaluated over fifty patient consultations to provide a comparison between remote consultation and face-to-face consultations.
• Equipped and trained staff in two rural centres to establish a pilot teledental service for restorative dental consultations.
• Completed a structured qualitative evaluation of the dentists' experiences and provided a comprehensive economic analysis of the pilot teledental service.

The key findings were that:

• Seventy percent of patients in the main clinical areas for routine referral were effectively managed by teledentistry in this trial
• The quality of images was found to be a major factor in the consultation outcome.
• Thorough initial training of GDPs to use the technology, ongoing training to maintain skills and frequent use of teledentistry were identified as important factors that enable GDPs to refer effectively
• There was a high level of Patient acceptance and satisfaction with videoconference consultations
• Teledentistry is a cost-saving technology from both the health care funder and the societal perspectives
• A 'low cost' teledentistry consultant service for restorative dentistry with experienced staff and appropriate technical support has a place in the delivery of dental healthcare services to remote communities
• Teledentistry consultations provide both formal and informal learning opportunities and alleviate the professional isolation of working in a remote community

Objective: This presentation informs participants about the history and evolution of telemedicine initiatives in the Bristol Bay Area. From the beginnings of medical traffic via aircraft radios to current telemedicine and teleradiology capabilities, technological innovations reduce the distance between providers and patients. The importance of telemedicine to the delivery of health care in this remote area is reviewed.

Conclusions: Lessons learned during this evolution are offered as key ingredients to successful telemedicine projects.

This poster presents the results of survey to determine the existence and availability of reimbursement for telemedicine. The lack of private payer reimbursement was identified by the American Telemedicine Association (and its members) as one of the top three inhibitors to the growth of telemedicine in the United States. It was assumed that there was very little private payer reimbursement for telemedicine and that private payers would resist payment if requested.

The ATA decided to co-sponsor the survey with funding and resources from AMD Telemedicine. We expected to find very little reimbursement but hoped that the results might provide information that would help develop and promote reimbursement. The results challenged the assumptions. The survey was sent to all active telemedicine programs in the United States. Over 50% of the programs responded and the majority reported receiving private payer reimbursement on at least 25 states. In excess of 100 private payers currently companies reimbursing for telemedicine and many of those reported a surprising willingness to pay. Respondents also advise on processed to acquire reimbursement from private payers and these were included in the survey results. The findings were first presented at the ATA meeting in April 2003 and have been updated.

Mr. VanderWerf joined AMD Telemedicine (then American Medical Development) as a Vice President in 1991. He was instrumental in changing the Company's focus from traditional medical products to telemedicine and was named President 1994.

Prior to AMD, Mark was a New Ventures Manager for Digital Equipment Corporation (DEC) where he managed the Company's entry into a variety of new service businesses. Prior to New Ventures, Mark served Digital as an internal consultant and an international corporate program manager.

Prior to Digital, Mark was Assistant Corporate Director for Samaritan Health Services in Phoenix, Arizona. This included management of the health network's radiology film library.

Mark is the author of "The American Healthcare System" published in Trading With The USA by the United Kingdom Department of Trade and Industry. He is a lecturer for the University of Hawaii Telemedicine Certificate Program, teaches telemedicine issues at the annual EMTN Telemedicine Technology Symposium and is a speaker on telemedicine at conferences and universities around the world. He serves on the Peer Review and the Awards Committees of the American Telemedicine Association and is a member the Board of Directors for the International Society for Telemedicine. Mark holds a Bachelors Degree from the University of Wisconsin.

Mark is the 2003 recipient of the New England Business and Technology Leadership award as among the top ten technology executives in the region.

Outside of AMD and telemedicine, Mark manages the Community Table program providing meals to less privileged and is a member of the Board of Directors of the New England Quilt Museum. He is also an avid traveler, sailor, and a very proud husband and father.

In 2000 the International Society for Telemedicine (ISfT) asked AMD Telemedicine to present our observations of what characteristics appeared to be common to successful telemedicine and telehealth programs. To find out, AMD Telemedicine conducted a study of over 60 telemedicine programs in three countries. During this review, we identified ten basic points and documented successful and unsuccessful approaches to each. There are exceptions, but the approach to each of these issues appears to maximize the likelihood of success or failure. The findings were initially presented to the ISfT membership at their conference in Denmark. The study has been updated continuously as new information becomes available. The most current observations are described in the presentation.

These ten basic points or characteristics are common to almost any program that attempts to bring change to an organization. More that anything else, a telemedicine practitioner must realize that the proper introduction and management of change is essential.

Nancy Vorhees is Chief Operating Officer for Inland Northwest Health Services (INHS), a regional non-profit healthcare corporation based in Spokane, Washington. Nancy directs several divisions of INHS including Northwest TeleHealth, Northwest MedStar, Community Health Education and Resources and Children's Miracle Network, among several others. All the divisions under Nancy's direction serve to integrate the delivery of healthcare services throughout the Inland Northwest. Regional economic development and removal of barriers to regional health care are the focus of her work.

As Chief Operating Officer, she has overseen the inception and development of the telehealth network including grant projects from the Office for the Advancement of Telehealth under HRSA, Rural Utilities Services and QWEST Communications. One project, Telepharmacy, developed a model whereby urban pharmacists fulfill the role of scarce rural hospital-based pharmacists with a potential to reduce expensive medication errors while controlling inventory. A second project developed a large integrated IP-based hospital informatics and telehealth network serving hospitals, mental health centers, corrections facilities and physician offices.

Expanding on existing collaborative relationships between competing hospital systems has proven to be a successful model in developing integrated delivery networks. From unexpected partnerships to regulatory buy-in, the convergence of technology and applications is providing solutions to shrinking budgets and critical healthcare issues. These solutions are also improving the awareness and recognition of the value and power of expanding telehealth networks.

Collaborative activities between two competing health systems in Washington State have led to the development of a widespread health informatics and telehealth network serving over 50 hospitals, mental health agencies, Native American health clinics, corrections facilities and physician offices in Washington and Idaho. The network incorporates a common electronic medical record and telehealth to the majority of connected hospitals.

In addition to the cost benefit of sharing networked systems and resources and growing telehealth utilization, a variety of applications have evolved taking advantage of existing infrastructure, complementary applications while delivering solutions to today's healthcare challenges. TelePharmacy and TeleTrauma have emerged as applications with great potential to reduce medical errors while providing cost effective solutions to health professions shortages.

As the need for electronic communication continues to grow, telehealth networks are recognizing a need to collaborate with a new set of partners. A growing need to bridge between networks and encourage developing partnerships is driving the need for state and regional healthcare linkages. EMS agencies, state and local health departments, community health centers, higher education and others are adding to a growing list of partners who would benefit from routine access to a common telehealth link. As evidenced through its recent connection to a North Idaho network of hospitals, these linkages encourage the use and growth of telehealth applications.

Dr. Weinstein graduated from Tufts Medical School, did his internship and residency in pathology at Massachusetts General Hospital in Boston and was a teaching fellow at Harvard Medical School. At age 27, while a resident, he was named Director of the Mixter Laboratories, thus becoming one of the youngest laboratory directors at Harvard. By the end of his residency, he was well published and lecturing on membrane superstructure at national and international meetings. He served as a major in the US Air Force and became Chairman of the Department of Pathology at Rush Medical College in Chicago in 1975, a position he held for 15 years. He has been Head of the Department of Pathology at the University of Arizona College of Medicine for 12 years.

Dr. Weinstein is a pioneer in the field of telemedicine. He carried out initial human performance studies on video microscopy and invented robotic telepathology for which he hold US Patents. He has published over 400 papers, book chapters, reviews, and editorials. Dr. Weinstein serves on the editorial boards of many journals. He has been president of the United State and Canadian Academy of Pathology, the Internal Society of Urological Pathology and the International Council for Societies of Pathology and is currently President-Elect of the American Telemedicine Association.

In addition to his position as Department Head, Dr. Weinstein is founding Director of the Arizona Telemedicine Program. Today, the Arizona Telemedicine Program links over 100 sites, including hospitals on the Navajo, Hopi and Apache Indian reservations, state prisons, and mental health centers in Arizona, New Mexico, Nevada, and Utah. It has provided over 125,000 teleconsultations, runs telemedicine research and education programs, and has received 7 national awards. Dr. Weinstein has served as president of three international professional societies, is currently president of the American Telemedicine Association, has over 400 professional publications, and has received many awards and honors including the Arizona College of Medicine's Lifetime Teaching Award.

Pamela Whitten, Ph.D., is an associate professor in the Department of Tele-communications at Michigan State University and a Senior Research Fellow for Michigan State's Institute of Healthcare Studies. In her current position, Dr. Whitten is responsible for conducting technology and health-related research as well as teaching graduate and undergraduate telecommunications courses. Dr. Whitten's research focuses on the use of technology in health care with a specific interest in telehealth and its impact on the delivery of health care services and education. She has served as the principal investigator on more than a dozen federal and state-funded telemedicine research projects. Her research projects range from telepsychiatry, telehospice and telehome care for COPD and CHF patients to wireless telehealth for nursing home residents and development of online health sites for low literate adults. Dr. Whitten has published dozens of peer-reviewed articles in a wide range of journals, as well as the 2001 book entitled, E-Health, Telehealth & Telemedicine. She currently has an edited book in press with Jossey-Bass, entitled Understanding Health Communication Technologies: A Case Book Approach.

Prior to joining the faculty at Michigan State in 1998, Professor Whitten ran the telemedicine program for the state of Kansas through the University of Kansas Medical Center. In this role, she was initially responsible for developing a sustainable telemedicine organizational and economic infrastructure, and subsequently managed all telemedicine operations at the University of Kansas Medical Center. Under her administration, the telemedicine program evolved into a system that made dozens of medical services available to clients located at rural hospitals, mental health centers, patients' homes, elementary schools, and a jail. In addition, she was responsible for implementing a wide range of health education programs for health providers as well as for the general population.

Rob attended the University of Western Ontario and did his family practice residency at St. Michael's Hospital in Toronto. He was Chief of Staff at the Timmins and District Hospital in Northern Canada from January 1985 until October 2000. He has been a member of the medical staff since 1976 doing general practice and emergency medicine.

He initiated the North Network with his partner Dr. Ed Brown in 1997 and is the Clinical Director. He was a Commissioner on the Health Services Restructuring Commission from 1996 to 2000 and has been active throughout his career in reshaping and restructuring health services in Ontario.

NN actively manages the design of the e-referral network respectful of the existing face-to-face referral network. NN recruits and pays an honorarium to local MD champions in each community to help understand local community needs as well as to whom and where patients are referred, and to promote telehealth services to colleagues within their community. NN recruits specialists from their usual referring center based on these identified needs.

NN designed the clinical operations to be as simple to use for the health professional as in face-to-face consults. One stop scheduling was developed and customized software was created to automate many parts of the scheduling process. The referring professional sends their referral to our scheduling office and the appointment is scheduled around the consultant's availability without further input from any of the professionals. Consultants who see a high volume of patients on our network are offered recurring block bookings. The video workstation is brought to the consultants' face-to-face clinics where possible and for very high users, a workstation is installed in their office. Each site where patients attend has a trained nurse coordinator to assist in the presentation of the patient. Patients are registered as an outpatient at both the patient and consultant location which assists NN to obtain relevant lab/imaging for the consultant and to ensure a health record is maintained. Clinical protocols are developed for each consultant and all coordinators are trained by NN so they can meet the unique needs of each consultant when presenting a patient.

NN pays consulting MD's their normal fee when their provincial health insurer does not. NN also pays a special visit premium to recognize the added time that is required for the MD to do a video consult.