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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

326
Choosing an Oral Imaging Camera for Medical and Dental Applications
Chris Patricoski, MD,  A. Stewart Ferguson, PhD,  Greg Juchem, RN, BSN       
Alaska Native Tribal Health Consortium, Anchorage, AK
Oral imaging cameras (dental cameras) are used as video display and image capture devices.&nb