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 Pediatr