19
The Promise of Commercially Available Videophones for Long Term Care: Findings and Challenges
Debra Parker Oliver, PhD,1  George Demiris, PhD2         
1University of Missouri, Columbia, MO; 2University of Washington, Seattle, WA
Little has been done to try and improve the long distance caregiving experience for family members of nursing home residents. Family caregiving does not stop once an elder enters the nursing home, yet distance makes this quite complicated. Caregivers often experience guilt and residents can become socially isolated. This roundtable discussion will examine the use of videophones for several scenarios of interactions in various long term care environments outside the home. The discussion will address technical and socioeconomic issues of video mediated communication in long term care settings and potential ways videophone technology can intervene to improve the social presence of family members. The roundtable will review practical challenges pertaining to implementation and usability of videophone applications in institutional settings. Specifically, examples of videophone usage in a nursing home and assisted living setting will be reviewed. These include video-mediated psychometric assessment of patients, interaction among staff and patients, and resident and family members “virtual” participation in interdisciplinary care plan meetings. These examples will highlight issues impacting clinical outcomes, resident and family acceptance, the subjective quality (as perceived by participants) and objective quality (as measured by standardized tools) of video and audio features of commercially available videophones. Furthermore, future trends in commercially available video-telephony in health care will be presented.

21
Providing Accessible, Standardized Education for Perioperative Nurses
Pennie S Seibert, PhD,1,2  Tiffany S Whitmore, MPA,1  Carin Patterson,1,2  Caitlin S Otto,1,2 Nichole Whitener, BSN CNRN,1 Christian G Zimmerman, MD FACS MBA1   
1Saint Alphonsus Regional Medical Center, Boise, ID; 2Boise State University, Boise, ID
INTRODUCTION: The demand for nurses is a chronic obstacle for the medical industry to overcome. New graduates and practicing nurses in other settings often make the decision to apply for a surgical position with little or no knowledge about the function of a nurse in the operating room (OR).  Training for the OR is often a time consuming and costly process.  While some hospitals use preceptor programs to train nurses to work in the operating room, there is little standardization in training for either preceptors or nurses in the program. This can result in ineffective training, high rates of attrition, and gaps in instructions.  These problems are exacerbated in rural areas where there is a paucity of trained perioperative nurses and preceptors.  Telemedicine offers an ideal vessel to administer an established paradigm. METHODS: We developed a standardized perioperative nurse preceptor program that can be delivered in-person or via telemedicine.  The program includes standardized OR competencies to use in conjunction with the AORN Perioperative 101 online course.  Robots are stationed in the rural hospital OR to provide real-time instruction from a trained preceptor, located at the hub hospital.  We believe standardized training will increase the efficiency and productivity of the OR as well as improve recruitment and retention rates that can benefit both urban and rural facilities.  RESULTS:  We will detail the program we developed including challenges and solutions to program development.  We will emphasize the potential benefits telemedicine can bring to perioperative nursing education and the role of the hub hospital in initiating the program.  CONCLUSION: A standardized preceptor program that can be delivered in-person or through telemedicine has the potential to improve training for perioperative nurses and help alleviate the numerous problems hospitals currently face when trying to train nurses to work in the surgical setting.  Delivery of training through telemedicine allows for increased opportunities for nurses in smaller hospitals to maintain competencies and stay current on advances occurring at larger hospitals.

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Perceived Satisfaction With Telemedicine Consults for Primary Care: A Longitudinal Study
Oscar Boultinghouse, MD, FACEP,1  Georges Brooks, MD,1  Glenn Hammack, OD, MSHI, FAAO,1  Alexander Vo, PhD2     
1Electronic Health Network, University of Texas Medical Branch, Galveston, TX; 2AT&T Center for Telehealth Research and Policy, El, Galveston, TX
INTRODUCTION: Most literature assessing patient satisfaction with telemedicine consults is done at the point of care (immediately following services) and may not reflect true outcomes beyond this time frame. This study attempts to measure patient satisfaction with telemedicine consults for primary care in two community clinics over a period of 2 years. METHODS: This study is a longitudinal repeated measures design of patient satisfaction with telemedicine consults for primary care services. Following every visit, patients were asked to complete satisfaction surveys measuring their level of contentment with care across three domains: quality of care, provider, and presenter. RESULTS: Preliminary data on 607 patients revealed that the average number of consults for all follow-up patients was 8 virtual visits. Data also indicated that satisfaction levels remained consistently high for various characteristics across all three domains for up to 25 months. No significant differences were detected for satisfaction with the quality of care, satisfaction with the provider, and satisfaction with the telemedicine presenter over time. CONCLUSION: There are two major implications of this preliminary data that are of paramount importance: (1) no other study has the kind of longitudinal data necessary for a long-term assessment, and (2) the quality of care is consistently perceived by the patient to be equivalent to on-site care. It is also important to note that the vast majority of telemedicine patients would recommend it to friends and family.

47
Telepsychiatry: One Insurance Company's Experience
Nancy Parrotta, LPC, NCC,  Salim Chowdhury, MD         
Community Care Behavioral Health Organization, Pittsburgh, PA
Community Care Behavioral Health Organization (Community Care), a non-profit, federally tax-exempt, behavioral health managed care organization (BH-MCO), manages behavioral health services for nearly one million members whose health coverage is sponsored through Medicaid, Medicare and commercial plans.  Of this number, 600,000 are Medicaid managed care enrollees in both urban and rural settings – more than any other BH-MCO in the Commonwealth of Pennsylvania.  Because of the shortage of psychiatrists in many PA Counties, mainly in child and other specialty areas, we took the initiative to look for ways to better serve the needs of our members.  Ideally, quicker access to mental health services should decrease the cost of emergency visits and inpatient hospitalizations. After some research, we made the decision to reimburse for services provided via telecommunication.  Utilizing the psychiatric resources of Western Psychiatric Institute and Clinic, an affiliate of the University of Pittsburgh Medical Center, we embarked on a collaborative project to implement telepsychiatric services to rural provider groups. We encountered numerous barriers along the way including physician reluctance with various concerns, provider lack of commitment, consumer hesitation with the new technology, and our initial lack of performance standards.  We continue to take an active role in this project to monitor its utilization and to ensure its benefits. Reimbursement is two-fold: payment to the physician as well as payment to a clinician at the originating site.  Member satisfaction is tracked utilizing the Service Satisfaction Questionnaire, Technology Evaluation Questionnaire, and Satisfaction with Telemedicine designed by Kopel, Nunn, and Dosseter (Journal of Telemedicine and Telecare, Vol. 7 (Supp. 2), 2001).  Our roundtable discussion will include our unique hands-on involvement as an insurance company, barriers overcome, lessons learned and the expansion of telepsychiatric services to our members in Pennsylvania.

48
Innovations In Telemedicine Based Eyecare
Sajeesh Kumar, PhD           
Centre of Excellence in e-Medicine, Lions Eye Institute , Perth, Western Australia, AL, Australia
PURPOSE: Non availability of eyecare specialist makes the rural regions vulnerable for blindness. This study aims to research, develop, implement and evaluate key components and strategies essential for effective and lasting eye care interventions in rural and remote regions. Lions Eye Institute (LEI) developed innovative, portable eye testing devices to reach remote regions which may not even have electricity and telecommunication facilities. The technology and methodology developed are affordable, transferable, and adaptable to the needs and realities of the developing world. The issues relating to this innovative mode of eyecare intervention are analysed. METHOD: Trained health worker at Carnarvorn Regional Hospital (CRH) used innovative testing devices and transmitted patient data to specialists at 940 kms away in Perth City. Diagnostic and management decisions were provided to all patients within 24 hours. Questionnaire and interview approach assessed the satisfaction of the patients and ophthalmologists. Economic data was gathered from the Department of Health, the CRH and the LEI. RESULT: Teleophthalmology proved to have impact on all the patients. Following teleconsultation, only 3 % of patients were referred to city hospital. 36 % of patients required regular follow up and 3 % of patients received treatment at CRH itself. The free exchange of service and ideas between city based specialist and rural healthcare workers is viewed as a catalyst for a positive change in rural eye care culture. Analysis further identified challenges faced between city-rural eye health service collaborations. CONCLUSION: This study provided access to specialist consultation and complex eye examinations to the remote regions. Study highlighted the importance of redefining utilisation criteria in order to achieve efficiency. This collaborative rural health programs are being devolved to Aboriginal patients so eye care can be controlled and delivered at the community level.

84
Delivering Successful Medical Distance Education Programs Through Technologies: Our Experiences
Jerrick Haddad,2  Brian Hammond,2  Douglas J. McClure, MIM,1  Joseph L. Ternullo, JD, CPA1     
1Center for Connected Health, Boston, MA; 2Partners Collaborative Media, Boston, MA
Since late 2001, a worldwide spike in interest in medical Distance Education programs has provided new opportunities for Partners Collaborative Media Services to showcase its technologies capabilities to audiences around the world. To become a successful program, however, required creating new processes and building relationships from the ground up.  The purpose of this roundtable is to discuss some of the key elements for creating a successful Distance Education program. Additionally we will be highlighting some of our experiences on this topic as they directly relate to the healthcare world, and what technologies assist us in achieving this goal.  Currently, our program has expanded to include five very successful client relationships connecting 24 countries. These relationships have provided us with a steady source of revenue.  Over a thousand physicians worldwide participate in these courses with many earning CME credits.   Such a strong Distance Education Program is impossible to achieve without careful implementation and planning to take a program from its inception, through negotiations, to operational excellence.  Our program enjoys this level of success because of the marriage between the operational arm and the technical arm of our group. During this roundtable we will identify the processes and technologies that have proven invaluable for seamlessly bridging the gap between lecturers and students. We will also look at promising emerging technologies we plan to integrate into our programs in the coming year.  

105
Implementing Telehealth in Schools, Clinics and Correctional Facilities
Diane E. Farrell-Castelli, RN, MS, MSN           
AMD Global Telemedicine, Inc., North Chelmsford, MA
The purpose of this presentation is to educate nurses, administrators and/or IT personnel regarding how to successfully implement telemedicine applications in elementary-based schools, public health clinics, and juvenile or adult correctional facilities.  Corrections and Education administrators, IT personnel and Nurses, Nurse Educators, Nurse Managers, Clinical Nurse Specialists, and Advance Practice Nurses, are being challenged to learn about telemedicine. They are required to use audio and video devices, videoconferencing systems, capture, store, retrieve or send audio sounds and/or digital images, navigate both computer and medical software applications, and schedule and manage a patient/physician videoconference encounter from a distance. Utilizing experience conducting over 200 implementations with various organizations, the presentation will focus upon key success factors and action items necessary to  implementing telemedicine programs in the school-based setting, public health clinics, and/or correctional facilities.  In conclusion, as Clinical Telemedicine/Telehealth programs increase there will be an increased need to educate nurses, administrators and IT personnel to implement and manage various type of clinical applications and specialty programs. Upon conclusion of this round table presentation, attendees will have a basic understanding of the importance of planning for a successful implementation and use of equipment, such as, audio devices, video cameras, software applications, and videoconferencing systems. They will also understand key success criteria for preparing patients for medical consultations, providing remote patient education, and conducting telehealth-delivered care.

119
Justifying The Deployment of Telemedicine Equipment During Terrorist Attacks
Richard Aghababian, MD           
University of Massachusetts Medical School, Shrewsbury, MA
Deployable Telemedicine applications, notebook computers, portable teleconferencing applications and telecommunication systems should be used during certain disaster responses. Such equipment and capability would allow medical responders to access experts who have had experience with similar events or medical consequences.  The medical response to the 2001 spread of weaponized anthrax spores via the U.S. Postal service in New York City is an excellent example of a response that would have been more effective had telemedicine linkages been available.  Medical responders had no experience with the management of victims exposed to weaponized anthrax spores. Media information provided to the public and to exposed postal workers was not always consistant with information provided by government sources. Some exposed individuals had complex medical histories and nonspecific signs and symptoms. Many questions being asked by exposed individuals could not be answered by on site medical responders.  Teleconferencing would have allowed experts at other locations to discuss with on scene responders the best approach to victim management and to help address complex questions from the exposed population.

126
Lessons Learned:  What Works in Telehealth Programs...and Why
Cindy K. Leenknecht, MS, APRN, BC, CCRP,1  Krisan Palmer, RN2         
1St. Vincent Healthcare, Partners in Health Telemedicine Network, Billings, MT; 2Atlantic Health Sciences Corporation, Saint John, New Brunswick, Canada
Many years experience in establishing and maintaining successful telehealth networks have provided examples of challenges faced and approaches taken to meet these challenges.  There are numerous factors that contribute to success and failure of individual applications/programs.  A number of examples from practical experiences will be presented, illustrating some of these challenges, approaches taken, and outcomes that resulted.  As would be expected, many lessons have been learned.  During this session, a telehealth nursing perspective will provide a backdrop for an overview and discussion of common characteristics, challenges, and strategies that have been implemented in successful programs within the United States and Canada.  Discussion of challenges faced in other telehealth practice environments will be encouraged and welcomed.

148
Military, Civilian collaboration in National Disaster Medical System (NDMS) Activation for Mass Casualties (MASCAL)
Colin  Mackenzie,1  John Donohue,2,6  Woody Cullum,6  Philip Wasylina,3 Chris  Handley,1,2 Jon Mark Hirshon,1 Peter Fu - Ming Hu,4 David Lam,1,5 Tony Story,5 Ron Poropatich5
1National Study Center for Trauma and EMS, Baltimore, MD; 2Maryland Institute for Emergency Medical Services, Baltimore, MD; 3Walter Reed Army Medical center (WRAMC), Bethesda, MD; 4Shock Trauma Center, Baltimore, MD; 5Telemedicine and Advanced Technology Research Center (TATRC), Frederick, MD; 6Baltimore Washington International Airport, BWI, MD
INTRODUCTION: Efforts are needed to coordinate military and civilian medical mutual aid using NDMS. The Airport, Academia, Industry, Military, State (AAIMS)  Functional Exercise ( FX) evaluated the bed ‘surge’capacity of Maryland NDMS Hospitals in response to outside continental U.S. (OCONUS) military MASCAL event. METHODS: The FX used Homeland Security Exercise Guidelines to evaluate reception, triage, and transport of 160 notional patients (20 live moulaged ‘patients’) and one dog. Military MASCAL patient manifest was delivered 24 hours before arrival via C-130 aircraft, triage, tagging, stabilization and transport to NDMS civilian hospitals. Triage tested the functionality of the Forward Deployable Digital Treatment Facility (FDDMTF), a transportable 20 bed , military developed resource available for MASCAL reception. A ‘Hotwash’ debrief followed the FX. RESULTS: NDMS training was carried out for more than 120 EMS/Military personnel. The Medical Mutual Aid agreement worked well as 160 notional patients were received, triaged and dispatched to military and civilian hospitals within 2 hours. Nineteen live ‘patients’ were transported by ambulance to civilian NDMS hospitals and administratively admitted. One acutely ill ‘patient’ was taken to a Maryland State Police Helicopter for urgent evacuation. The one notional dog (animal handling is part of NDMS) revealed deficiencies in companion/military animal reception, holding, treatment and evacuation. As a result of AAIMS 21 recommendations were made and three working groups (WG 1-3) formed: WG1: Ensure 100% compliance with triage tags, patient accountability and return of equipment used in MASCAL events and exercises. WG2: Make information technology and imaging networks available for EOCs and Incident Command. WG3: Establish NDMS Training, Education, and Evaluation groups. CONCLUSIONS: AAIMS optimized military/state inter-agency cooperation and planning for activation of NDMS response. AAIMS facilitated revisions of the Maryland Emergency Operations Plan across all key state emergency response agencies. The AAIMS recommendations likely apply to the vast majority of NDMS activities within the United States. SUPPORTED BY: W81XWH-05-2-0086 Telemedicine & Advanced Technology Center (TATRC)

155
A State of the States Assessment of Telehealth for Kansas, Michigan and Indiana
Pamela Whitten, PhD,1  Bree E Holtz, MSc,1  Norbert Belz, MSHA, RHIA,2  Bart Collins, PhD,3 Rose Young, RN, MSN,4 Sally Davis, MA4   
1Michigan State University, East Lansing, MI; 2University of Kansas Medical School, Kansas City, KS; 3Purdue University, West Lafayette, IN; 4Marquette General Hospital, Marquette, MI
INTRODUCTION: The Midwest Alliance for Telehealth and Technology Resources (MATTeR) is a Telehealth Resource Center for the Midwest, formed through an existing partnership in Michigan, Indiana and Kansas.  MATTeR aims to provide support to existing and developing telehealth networks to meet the needs of rural and underserved residents within the Midwest. OBJECTIVE: MATTeR sought to determine the current state of broadband access and telemedicine activities through the partnered states in order to establish a baseline of technical and programmatic infrastructure to be employed in regional design, planning and deployment. Using the MATTeR region has an example, other programs can utilize this information to assist their programs to achieve sustainability and promote growth. METHODS: Researchers conducted phone surveys to healthcare entities in Michigan, Kansas, and Indiana, with particular emphasis placed on Critical Access Hospitals, Federally Qualified Health Centers, Public Health Departments, and Community Mental Health Services.  Surveys were administered to personnel from the facilities’ information systems/technology and or telemedicine departments.  If the participants preferred, the survey was also available online for completion. RESULTS: Access to video-conferencing equipment was widely available in these facilities, however, they were not fully utilized into continuum of patient care.  If the facility had telemedicine applications, the number of consults ranged from five to over 1000 per year.  Because so much of telehealth for organizations hinges on their information systems backbone, MATTeR also investigated the type of access and organizational procedures around these systems.  Data demonstrated that over half of the facilities reported having a formal information technology plan in place.  An overwhelming majority also stated that they had access to broadband Internet access. IMPLICATIONS: Understanding the technical and programmatic infrastructure for a region is a critical step in large-scale planning for service and policy needs.  Lessons from this assessment can be employed by other U.S. regions to match extant infrastructure and programs with future needs.

168
Developing An Integrated Foundation for a Telehealth Program at VIHA
Margarita Loyola, MBA, MEng, PEng,  Cathy Wenger, BA, BSc         
Vancouver Island Health Authority, Victoria, British Columbia, Canada
The implementation of a widespread, robust telehealth program at the Vancouver Island Health Authority (VIHA) is in its infancy. The planning, implementation and evaluation of this program is being conducted from an integrated approach at both the provincial and organizational level. The VIHA is one of six regional health authorities within British Columbia, which in turn are governed by the Provincial Ministry of Health. The Health Authorities, together with the Ministry of Health are establishing telehealth initiatives in a collaborative environment that promotes interoperability through the establishment of joint standards, guidelines, and policies and procedures.  This integrated approach to provincial telehealth development is mirrored internally, as telehealth initiatives are being aligned with other internal strategic initiatives that include the delivery of clinical, educational, and administrative healthcare services. This approach supports the demand-driven evolution of telehealth programs and is reflected in the incorporation of telehealth into the planning, implementation and policies of mainstream services.  The cultural, demographic, and geographical landscape of Vancouver Island lends itself to reap the benefits that telehealth offers. Through a network of hospitals, clinics, centers, health units, and residential facilities, the Vancouver Island Health Authority provides health care to over 730,000 people including 51 First Nations Bands. The VIHA telehealth program aims to provide this dispersed and varied population with timely and comprehensive access to health services in an efficient manner.  Currently at the VIHA, there are several telehealth initiatives underway that include, TeleOncology, TeleThoracic, TeleMental Health and Addictions, and TeleHomeCare.  These initiatives are being undertaken in the face of barriers that include; physician reimbursement, non-standard devices and technologies, and lack of a secure, integrated provincial network (including a scheduling system).  The VIHA and its provincial partners continue to work together to overcome these barriers and look to expand services to include; TeleOpthamology, TeleChronic Disease, & TeleUltrasound.
 
170
Distance Education Impacts Quality of Care
Deborah Peters, MS,1,3,4  Tom Brewer, MSIPC1,2         
1St. Vincent Healthcare, Billings, MT; 2Partners in Health Telemedicine Network, Billings, MT; 3Northwest Research and Education Institute, Billings, MT; 4Rocky Mountain Health Network, Billings, MT
There has been a very serious need for continuing education for healthcare professionals in the Northern Rocky Mountain region. Montana, Wyoming, and Idaho lack medical schools and the associated benefits of academic medical research and continuing education.  People are very isolated from one another; the population averages less that six people per square mile in most counties. Internet access is unreliable or inaccessible. Travel over the vast open plains and mountainous terrain may be treacherous. In many cases, attending educational conferences is cost-prohibitive; when physicians do leave, their patients and communities are left without access to any healthcare.  What is the solution? How do you provide quality continuing education to healthcare professionals under these circumstances? Can quality of care be improved through education of healthcare professionals who serve at risk populations, especially the elderly who live in extreme rural locations, Native Americans and other at risk populations?  In 2004, St. Vincent Healthcare and Rocky Mountain Health Network,  located in Billings, Montana established Northwest Research and Education Institute (NWREI) to address these problems. Together with the Partners in Health Telemedicine Network (PHTN), the telemedicine system associated with St. Vincent Healthcare, NWREI began to provide accredited continuing education to health professionals in extreme rural locations utilizing the videoteleconferenceing system. With NWREI providing content and PHTN driving the technology to make education accessible, utilization of PHTN for educational purposes increased by over 70% in the first year with continued growth of nearly 40% in the next two years. Steps have been taken to expand existing education and develop new programs to serve all healthcare professionals. NWREI’s educational needs assessment data and evaluation processes have been designed to assess how health care quality is improving as a result of this distance education.

175
Residents, Rural Providers, and the High-Risk Patient – Where Telemedicine Rescues
Samantha McKelvey, MD,  Paige Hare, RN,  Rosalyn Perkins, APN,  Rachel E. Ott, BA     
University of Arkansas for Medical Sciences, Little Rock, AR
Arkansas is state burdened with greater than average incidences of obesity, diabetes, and chronic hypertension.  In rural Arkansas, health departments generally serve as the intake point for high-risk pregnant patients suffering from these conditions; however, these facilities often do not have the medical expertise to care for high-risk pregnancies.  The majority of Arkansas’ subspecialists practice centrally in the state, often hundreds of miles from the rural women who need their care most.  Patients with these chronic high-risk conditions often need weekly visits throughout pregnancy, but travel to subspecialists impedes regular care.  Arkansas’ strength lies in its foresight and innovation.  With many of the state’s hospitals and health departments wired for telemedicine connectivity, a wealth of rural and tertiary center collaboration possibilities have emerged.  Using interactive telemedicine, rural providers provide high-risk patient care throughout pregnancy with the guidance and close consultation of senior-level residents.  Residents have acted as ideal candidates to provide relief to rural providers treating high-risk pregnancies.  Available for frequent and on-the-spot consultation, residents can provide the ongoing, attentive care needed for high-risk conditions.  Telemedicine furnishes the interactivity needed to collaborate, closely monitor, assess, and treat these patients remotely, while preparing these women for delivery at the tertiary center. This practice also provides residents with hands-on medical experience using technology essential in their roles as future physicians.  Residents have noted that telemedicine interaction with rural patients has prepared them to serve rural communities later in their careers.  Further, residents have emphasized the importance of building bonds with outside physicians and nurses in Arkansas, relationships that have frequently resulted in future collaboration in their practice.  Residents, rural patients, and their providers alike benefit from residency-driven high-risk telemedicine consults.  Telemedicine empowers residents to gain new skills, relieve busy subspecialists, and build new relationships before venturing into their medical careers. 

177
Disaster in the Rural South: Strategies for Hospital Telemedical Training
Michael O Manley, BSN, RNP,1  Curtis Lowery, MD,1  Tina Benton, BSN, RN,1  Cathy Flanagin, MA,2 Rachel E. Ott, BA1    
1University of Arkansas for Medical Sciences, Little Rock, AR; 2Arkansas Department of Health and Human Services, Little Rock, AR
Never before has the need for telemedical training been greater in the rural south.  Having faced hurricanes, natural disasters, and threats of terrorist attacks, hospitals in the south have leaned on the innovation of telemedicine to communicate with neighboring healthcare facilities.  Upon assessing the level of telemedicine knowledge in rural hospitals, ANGELS found a general lack of experience in operating telemedicine equipment. Further, on-site visits discovered many hospitals still had telemedicine equipment uninstalled and non-operative, often left to the hospital’s maintenance man for safe keeping. To address these concerns, the Arkansas Department of Health and the University of Arkansas for Medical Sciences’ Center for Distance Health (CDH) initiated a program in Arkansas’ rural emergency departments (ED) using existing bioterrorism telehealth lines to train users to utilize and maintain communication.  This effort affords the training required to easily interact through telemedicine in the event of a disaster and to encourage increased communication between Arkansas’ hospitals.   Establishing regular telemedicine-driven training sessions, practice drills, on-site and distant education, and a yearly virtual conference, trained telemedicine experts have collaborated with small, rural EDs seeking to learn the implications of this new technology.  This essential effort supports users of bioterrorism telehealth equipment by providing guidance required to react to natural and medical emergencies in a timely and orderly fashion. ANGELS has devised an ED telemedical training protocol to ensure all users are comfortable and ready to respond to a disaster using telemedicine.  Without the necessary equipment setup and personnel training, telemedicine is little use to the rural hospital.  ANGELS provides a model training program to follow in delivering this education to new users working in the busy hospital environment.  This succinct, efficient training is often all that is needed to get a hospital connected to their neighbors.

180
Improving Prenatal and Postnatal Genetic Care through Telemedicine
Shannon Barringer, MS, CGC,  Shannon Lewis, BSN, RN,  Julie Hall-Barrow, EdD,  Nafisa Dajani, MD, Rachel E. Ott, BA    
University of Arkansas for Medical Sciences, Little Rock, AR
The incidence of medically significant congenital anomalies in the United States averages 1 in 33, or approximately 3%.  However, Arkansas’ incidences of neural tube defects and facial clefting remain significantly higher than the national average, and 20% of all infant deaths in the state are attributable to birth defects. In an attempt to increase providers’ knowledge bases and increase interaction between the prenatal and pediatric subspecialists caring for these babies, the Center for Distance Health developed FAIM (Fetal Anomaly Interdisciplinary Management).  This cross-organizational and multi-disciplinary teleconference aims to present the prenatal and postnatal diagnosis and management of a variety of birth defects, especially those common in Arkansas.  FAIM invites providers to use telemedicine to review normal and abnormal prenatal ultrasound/MRI findings; refine diagnoses; establish better management plans; discuss recurrence risks, prognosis, and /or prevention; and review new medical technologies that may aid in the overall care of these babies. Monthly teleconferences originate from Arkansas Children’s Hospital and are broadcast via telemedicine to several locations around the state.  Maternal-Fetal Medicine physicians, genetic counselors, radiologists, and ultrasonographers review two to three patient cases whose fetuses have been diagnosed with a particular anomaly.  Presentations include pregnancy histories, ultrasound images, and other laboratory and screening results.   Postnatal presenters include appropriate pediatric subspecialists who provide hospital stay information, surgical reports, pathology images, and social work concerns.  Specialists in fetal intervention, including surgery, have provided information via telemedicine from other institutions around the country.  Epidemiologists from the CDC have also provided information regarding incidence and reduction of risk for particular birth defects. FAIM participants have agreed that reviewing these case studies have provided the collaborative atmosphere necessary to comprehensively review genetic disorders seen among Arkansas’ women.  Teleconferencing provides the ideal platform to discuss these complex genetic conditions, while arriving at better management strategies for future cases.

210
Distance Learning in Health Care: New Opportunity for Open Source Technologies
Patricia Abril-Jimenez, MSc,1  Maria Fernanda Cabrera Umpierrez, PhD,1  Maria Teresa Arredondo Waldmeyer, PhD,1  Evangelos Bekiaris, PhD2     
1Universidad Politecnica de Madrid, Madrid, Spain; 2The Centre for Research and Technology Hellas, Athens, Greece
The necessity of continuous formation in health professionals has an important help in the distance learning. In this sector, the e-learning platforms emphasize because they allow the ubiquitous access to relevant content, making possible the communication and the collaboration between students and trainers. All together, becomes mean of continuous adapted formation to workers, with great advantages on the actual formation.  The created distance learning platform consists of a complete learning management system to support staff’s distance learning, based in open source software. It is a web portal, designed for all W3C compliant web browsers and compatible with different operating systems. The open-source structure makes it long-life updatable about contents, appearance, new tools, sources, etc. The information is stored in a SQL database and can be modified by the administrator in order to improve course quality by adding new information or modifying the existing one. The information in the database observes confidentially and security requirement. The distant trainees’ communication needs are solved by means of synchronous and asynchronous tools. These allow users to exchange information and questions with other peers or with the courses instructors. An automatic assessment system analyses the user’s answers, computes scale scores and compares them with cut-off scores so that users become informed about their progress and/or knowledge lacks. New tools have been developed to provide additional information to trainers and employees (RSS news, direct access to related web pages, and guided search in web site). The interface is user-friendly and usable by people without good PC knowledge and expertise and a video tutorial is also available for navigation help.  The platform is being evaluated in three pilot sites (France, Greece and UK). The initial results of this validation are very positive in the following factors: satisfaction, efficiency, helpfulness and controllability.

244
Patient Acceptance of a New Home Heart Failure Monitoring Program
Regina Nieves, RN,1  Alice Watson,  MBChB, MRCP, MPH,1,2,3  Ambar Kulshreshtha, MBBS, MPH,1,2,3  Kimberly Harris, MM,1 Joseph Kvedar, MD1,2,3    
1Center for Connected Health at Partners, Boston, MA; 2 Massachusetts General Hospital, Boston, MA; 3Harvard Medical School, Boston, MA
BACKGROUND: Heart failure is the number one reason for hospital admissions in the over 65-age population.  A previous study demonstrated telemonitoring of homebound patients reduced hospital readmissions by 25%.  Partners Healthcare launched a quality improvement program utilizing remote monitoring of non-homebound heart failure patients to improve patient outcome and reduce cost amongst this patient population. METHODS: Hospitalized patients with heart failure were identified and offered the opportunity to participate in the program.  Their physician’s agreement was also required.  Participants had home telemonitoring equipment installed and were required to send daily vital sign and symptom reports to a telemonitoring nurse.  Timely interventions and teaching were offered over the 6-month course of the program.  At the end of the program, all patients completed a satisfaction survey. RESULTS: Of the 81 people found to be eligible only 42 ultimately enrolled in the program.  Of the remainder, 23 patients refused to participate and 16 physicians declined consent.  Reasons for refusal by patients and physician varied widely.  Patients most commonly declined to participate because they were too busy, unsure of the technology, or worried that monitoring would make them feel disabled.  Physicians most frequently cited dislike of technology, fear of information overload and doubt that their patient would cooperate as reasons for refusal.  Initial feedback from participants has been overwhelmingly positive with 100% of patients reporting that the program has improved their overall health and helped them stay out of the hospital. CONCLUSIONS: Telemonitoring has the potential to greatly improve outcomes in patients with heart failure and our program has been well received by participants.  However, significant barriers to adoption exist amongst patients and providers and these must be addressed and overcome to fully realize the benefits of this program. 

246
Basic Emergency Nursing Education via Interactive Videoconference: The Washington Emergency Nursing Education Council
Kathleen L. Emde, RN,MN,CEN,FAEN           
Washington Emergency Nursing Education Council (WENEC), Redmond, WA
The Washington Emergency Nursing Education Council (WENEC) wsa formed in 2001 to meet the need for a statewide basic emergency nursing course.  A group of emergency nurse educators met and developed curriculum to meet this need.  The 8 day Basic Emergency Nursing Course came out of this group's work.  Funding for the course was provided through hospitals joining the council as members, and through a per head fee for attendees at the course.  The course was initially offered as a live lecture course,  then was offered statewide to member hospitals using interactive videoconferencing.  Offering the conference statewide created a need for a cooperative offering involving both the University of Washington Telehealth Network and the Inland Health Services (INHS) Telehealth Network.  The course has been offered each Fall and Spring since its development, and to date several hundred new Emergency Nurses have been educated.  The beneficiaries of the course include many isolated rural hospitals who would not otherwise have access to this level of educational offering, due to barriers such as distance and costs of travel and lodging.  The level of satisfaction among member hospitals has been high and the initial member hospitals have remained supporters of the course.  The course has been offered in multiple states over the past two years, including Northern Idaho, Montana and Wyoming.  WENEC has remained committed to providing quality emergency nursing education at low cost to rural and urban hospitals, and has been able to meet an ongoing need as emergency nurses become ever more scarce.  WENEC plans to continue to offer the course twice each year as long as a need exists.

291
Teaching Teachers: Closing the Gap Between Health Care and Education
Kathleen Tyler Davis, PhD,1,2,3  Ryan Spaulding, PhD,1  David Cook, PhD1       
1Center for Telemedicine and Teleheath at the University of Kansas Medical Center, Kansas City, KS; 2Department of Pediatrics at the University of Kansas Medical Center, Kansas City, KS; 3USD #500 Kansas City Kansas School District, Kansas City, KS
Students with chronic health conditions are at the intersection of health care and education.  School attendance is affected by disease exacerbations, treatment and doctor appointments.  When the student is able to go to school, the focus is often on the health of the child and the education of the student may not receive the attention necessary to ensure that the youngster continues to enjoy academic success.  Teachers, other education professionals, and peers often do not know how to support the student when he or she returns to school after a serious health diagnosis.  This problem is intensified in rural areas where information about chronic conditions of childhood may not be available at all.  Kansas has a significant rural area, with nearly half of its population living in rural areas.  Due to the rural nature of Kansas, many schools throughout  the state use interactive distance learning equipment to share education resources.  Connected Kansas Kids (CKK) is a telehealth project of the Center for Telemedicine and Telehealth at the University of Kansas Medical Center that addresses the needs of students with chronic health conditions.  Schools can use interactive distance learning equipment to connect to telemedicine equipment at the medical center.  This telehealth application enables communication between educators and health care providers in novel ways.  For example, hospital physicians, therapists and other health care providers can participate in conferences or Individualized Education Program (IEP) meetings with the student/patient’s home school.  In addition, parents who are miles away from home with their hospitalized child can participate in parent-teacher conferences with the home school.  Further, the pediatric education specialist can provide staff development to rural schools about specific chronic conditions of childhood and the potential effect on learning and achievement. 

297
Taking Healthcare Home - Balancing Productivity and Security
Randy Cleghorne,1  Andy Willett2         
1Visiting Nurse Service of New York, New York, NY; 2NetMotion Wireless, Seattle, WA
The proliferation of wireless networks and public Wi-Fi have created a surge in technology that can expedite and improve the quality of work for mobile healthcare professionals. A large number of hospitals and home care forces around the country have begun to adopt these technologies to manage patient records, for lab and test results, and to maintain connectivity to other network resources. This session will examine common obstacles in wireless deployments as well as specific case-study results from a mobile deployment with Visiting Nurse Service of NY. NetMotion will discuss their mobile deployment strategy and how they protect confidential patient records and sensitive data, while improving nurse productivity in the field. While mobile technology has clear benefits, often times these benefits are not immediately realized due to common problems with wireless deployments. In fact there are three key hurdles that IT managers face in mobile deployments. These include:

• Coverage gaps and interruptions. When a worker moves out of range, applications fail, forcing users to reconnect to the network, restart the application, and re-enter any lost data.
• Inter-network roaming. Workers must be able to seamlessly move between various data networks (wired, cellular wireless and Wi-Fi). More importantly, the healthcare worker should not have to manage each of these cases.
• Device Management. Lost and stolen devices have created new and very serious security challenges. When a device is lost or stolen, security protocols must be easy and quickly implemented. Additionally, IT managers need to create and assign policies to manage network access.

Because the healthcare industry is highly regulated, any mobile deployment must meet stringent data and network security requirements. Successful mobile deployments must strike a delicate balance between security, while surpassing common challenges. This session will examine each of these factors.

324
Medical Genetic Consultations-- Video vs. In-Person Visits Among Spanish Speaking Families
Jacquie L Stock, MPH,1  Michael Raff, MD,1  Susie Ball, MS, CGC,2  Deb Lochner-Doyle, MS, CGC,3 Ian A Glass, MD1    
1Seattle Children's Hospital and Regional Medical Center, Seattle, WA; 2Yakima Valley Memorial Hospital, Yakima, WA; 3Washington State Department of Health Genetic Service, Kent, WA
INTRODUCTION: There is a shortage of medical geneticists in the United States.  Public health agencies and tertiary centers where specialists practice seek ways to deliver medical genetic services to populations who live a significant distance from where specialists work. This study is the first report of a comparison of family satisfaction between interactive videoconferences and in-person medical genetic consultations among an English and Spanish speaking population, and of medical geneticist impressions of physical observations during video visits. METHODS: During a specified time period, all parents or caregivers of children who participated in a follow-up or initial medical genetic consultations via interactive videoconferencing (No.=29) or in-person (No.=28) visit completed written, self-administered questionnaires immediately following consultation from a medical geneticist. For video visits, families and a certified genetic counselor on site in Yakima, Washington, participated in consultation with a medical geneticist housed at Seattle Children’s Hospital.  Spanish interpreters were available for native Spanish speaking families. Surveys included questions about visit anticipation, auditory and visual communication, information comprehension, confidentiality, equipment, and willingness to use interactive videoconferencing again. Genetic providers completed post video visit satisfaction questionnaires and reported impression of physical observations. RESULTS: Mothers of children referred for consultation comprised the majority of family respondents in both groups.  Among video visit respondents, 53% reported their child was of Hispanic ethnicity. A t test statistic revealed no statistically significant differences in overall mean satisfaction with medical genetic consultations between families participating in a video visit and those participating in in-person visits. Both groups reported overall high (at least 4.8 on a 5 point scale) mean satisfaction with consultations.  The medical geneticist reported general satisfaction with video visits and described limitations to physical examination. DISCUSSION: Selective use of interactive videoconferencing can assure effective delivery of certain medical genetic services to families who might not otherwise receive these valuable specialty health services. There are limitations to complete observation of physical presentation.

328
Community Service Learning Supported by Telemedicine
Ana Maria Lopez, MD, MPH,1,2  Carol Galper, PhD1         
1University of Arizona College of Medicine, Tucson, AZ; 2Arizona Telemedicine Program, Tucson, AZ
Physician shortages are present in many parts of our country with most physicians choosing to practice in more urban settings. This maldistribution of resources often places the health care of persons in rural and remote areas at a disadvantage.  In order to begin to ameliorate this inequity and enhance the health services of our state, the University of Arizona (UA) College of Medicine initiated the Rural Health Professions Program (RHPP).  This Program has developed clinical educators in rural communities, paired clinical mentors with medical students early in their medical education--the summer between first and second year of medical school; and provided the opportunity for a longitudinal clinical experience across the 4-years of medical school. Despite the success of this program, practitioners often noted a sense of isolation as a drawback to rural practice. In order to address this concern and support the student and mentor, the UA is collaborating with the Arizona Telemedicine Program, to integrate tele-education and teleconsultation into the RHPP. This process is two-fold. Student/mentors are able to participate in Grand Round presentations originating at the UA. In addition, students receive hands-on training in tele-consultation and are required to be the presenter in both a real-time and store-forward teleconsultation. In this presentation, the educational goals and objectives of this Program modification, its implementation and student/mentor satisfaction with the program will be described and discussed.

358
Team-Based Approaches in Pediatric Telemental Health
Eve-Lynn Nelson, PhD,1  Kathryn Ellerbeck, MD, MPH,2  Kathy Davis, PhD1       
1KU Center for Telemedicine and Telehealth, Kansas City, KS; 2Center for Child Health and Development, KUMC, Kansas City, KS
National practice guidelines call for team approaches for common behavioral concerns including attention-deficit/hyperactivity disorder (ADHD), pediatric depression, and autism.  The benefits of team services included more thorough evaluation, greater compliance to evidence-based practice, and ultimately, enhanced outcome. But it is logistically difficult and costly for interdisciplinary teams to travel to distant sites.  It is often equally difficult for families to travel to the urban medical center, especially considering travel with young children with behavioral concerns.  Telemedicine offers a unique means to extend developmental and mental health expertise into the community.  Three team-based telemedicine services will describe evaluation and treatment of mental health concerns over televideo.  In 2006-2007, the teams completed approximately 160 joint telemedicine consults in diverse settings (e.g., schools, outpatient clinics, primary care, etc.) and populations (urban, suburban, and rural communities).   The ADHD and autism teams includes psychologist, developmental pediatrician, pediatric educator, and other allied health professionals depending on the case presentation.  The TeleHelp depression team includes child psychiatrist and child psychologist. Most team-based challenges are similar to face-to-face clinics such as time management, integration of different treatment perspectives, and organizational concerns around documentation, billing, and prescribing. The greatest challenge related to telemedicine is the complexity of integrating the high volume of information from school and home informants. The telehealth providers will give practical advice concerning implementing team-based practice over telemedicine including: establishing protocols, training staff, marketing to the community, and maximizing the completion and return of intake questionnaires.  This service model allows a unique way to train students from medicine, psychology, and other disciplines in evidence-based treatment for underserved families and in technology. The pediatric educator associated with the telemedicine clinics will describe addressing school concerns as part of the telemedicine team as well as adjunct web materials about child mental health concerns and academic needs.

449
Outcome Measures for Evaluating Chronic Disease Management Programs using RPM
Malcolm Clarke, PhD, Joanna Fursse, Russell Jones, MD
Department of Information Systems and Computing, Brunel University, Uxbridge, Middlesex, 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, but full analysis of the value of RPM remains to be reported. Projects and programs to date have concentrated on outcomes to evaluate cost benefit and cost effectiveness but relatively few have concentrated on clinical outcomes. This paper presents a review of the methodologies that have been applied to evaluate the outcome RPM projects. The purpose is to determine the full range of metrics that have been applied, compare their relative advantages and from analysis of best practice, propose frameworks that can be applied in future projects. Well known frameworks include assessing reduction of bed-days, reduction in admissions, patient satisfaction, cost analysis, and reduction in home visits. Issues include the methods to plan well conducted trials, what is the gold standard, is there a “silver standard”, how are  randomised controlled trials conducted, how are psychological effects separated from other effects? The priority of our work has been to determine the long term effects of RPM on the management of patients. Most of the frameworks reported to date have not been suitable for our purpose and instead we have compared physiological measurements to assess outcome. We wish to compare other clinical outcome based frameworks.

460
Telemedicine in International Disaster and Chronic Humanitarian Crisis
Randy S. Roberson
Humanitarian Emergency Logistics and Preparedness (H.E.L.P.), Payson, AZ
HELP utilizes multiple video and audio teleconference platform capabilities, tied to multiple medical peripheral devices (EKG, 02 Sat, Digital Stethoscope, various scopes, etc.).  These are housed in backpacks for initial response in hard to reach areas, and in HELP’s “Doc-in-a-Box” mobile medical clinics.  These are clinics housed in reused 20’ cargo containers, connected to the internet via satellite, cellular and other broadband access, to medical resources outside effected humanitarian crisis regions offering emergency providers the ability to address several critical disaster needs.  Primarily these grossly overtaxed surge capacity of local hospitals and emergency field responders.   Although operated by EMT and other “first-responder personnel,” significantly higher levels of medical review is offered from specialists looking over their shoulder via telemedicine link.  Patient data is tracked on the “MedWeb” database for initial and project follow-up analysis.  Likewise disaster site blogs offer the capability to archive video, photos and reports from various sites and overall disaster effort effectiveness.  The non-confidential information is shared openly on the web for agency partner’s reports, press releases and non-profit promotional benefits. 
Additional support partners include www.mypacs.net who receives over a million visits per month and has 4000 users worldwide. Possible utilization of volunteer and fee for service teleradiology by companies is also being pursued.  Cellular broadband, Wifi and Satellite communications technology is used, as with previous humanitarian work by HELP. Additionally HELP deploys the “Sahana Disaster Management Database” in all mobile clinics.  This provides open sourced situational awareness and disaster assessment data to all other entities – both local and international – who desire connectivity to this system.  Additional data which this tracks includes missing persons, geospacial situational awareness, assets, needs, and much more.   All in one 20’ cargo container that can be placed on a truck and taken to virtually anywhere, then tied to the rest of the world.