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POSTER PRESENTATIONS ABSTRACTS

P1STEPS TO HIPPA COMPLIANCE—THE CTA APPROACH,A PRESCRIPTION FOR SUCCESSElliott Abraham, MCSE, Nik Beaty, CPT Wes Burnett, BSTAMSCO, Fort Gordon, GA

Health Insurance Portability and Accountability Act (HIPAA)compliance will impact the entire healthcare industry. The newsecurity regulations of HIPAA are designed to protect the avail-ability, confidentiality, and integrity of patient data. In light ofthese new regulations, teleconsultation is just one of many busi-ness processes that must migrate to HIPAA compliance by 2002.Analysts estimate that the costs of HIPAA compliance will be 3to 4 times that of Y2K. Some even estimate the total to reach ashigh as $25 billion dollars.

The Center for Total Access, or CTA, has regional oversightof a Web-based, store-and-forward Teledermatology service. Inits original configuration, this service would not meet the HIPAAstandards for security. To develop a Teledermatology service thatmeets HIPAA compliance, the CTA has adopted a layered ap-proach to security. These layers consist of complex access con-trol lists on our routers, load-balanced firewalls, intrusion de-tection systems, and strong authentication systems, all builtaround the advanced Windows 2000 Active Directory platform.All servers will be further “hardened” against hack attacks byproactive probing and scanning to reveal and correct areas ofweakness.

P2CLINICAL EVALUATIONS OF TELERADIOLOGY: APRIMER FOR CONDUCTING AND EVALUATINGCLINICAL EFFICACY STUDIESZia Agha, MD, MS,1 Azhar Turab Ali, MD,3Craig A. Beam, PhD2

1Division of General Internal Medicine; 2Department of Radiology,Medical College of Wisconsin, Milwaukee, WI; 3Department of Radi-ology, Mayo Clinic Jacksonville, FL

Studies on the clinical evaluation of teleradiology vary in qual-ity because of a lack of established standards for conductingsuch studies. Our objective is to describe standards for clini-cal evaluations of teleradiology. We propose that researchaimed at evaluating the clinical efficacy of teleradiology shouldfulfill the following criteria: study purpose, design, and im-plementation: The study should provide evidence of researchplanning, use of a standard of reference, randomization in theorder of interpretation of images, observer blinding, and themeasurement of inter and intra-observer variability. Details ofhow the study was implemented, including the type and num-ber of subjects enrolled, how they were enrolled, and the num-ber excluded from analyses should be evaluated. Descriptorsof type of teleradiology, system/equipment, bandwidth usedfor transmitting images, and type of radiologic proceduresneed to be detailed.

Statistical Information: The evaluation should assess whethernumeric parameters of any kind (kappa statistics) are utilized,and if so estimates of variability (standard errors) should be re-ported. In addition, the statistical inferential procedure em-ployed (confidence intervals or hypothesis tests) should be as-sessed, and power analysis needs to be reported.

These standards will contribute to improve the quality of tel-eradiology research and provide clinicians with a framework tocritically evaluate teleradiology studies.

P3DIAGNOSIS OF NONDIABETIC OCULAR DISEASEWITH THE JOSLIN VISION NETWORK IN PATIENTSWITH DIABETES MELLITUSLloyd M. Aiello, MD, Sven-Erik Bursell, PhD, Anthony Cav-allerano, OD, Jerry Cavallerano, OD, PhD, Paula Katalinic, B.Op-tom, Kristen HockJoslin Vision Network Research Team, Beetham Eye Institute, JoslinDiabetes Center, Boston, MA

The Joslin Vision Network is the telemedicine platform for theJoslin Diabetes Eye Health Care program. Over 2000 patientshave had retinal imaging performed to determine level of dia-betic retinopathy and appropriate clinical management using theJoslin Vision Network.

While the JVN has been validated for determining clinical levelof diabetic retinopathy, the JVN is also useful in identifying ocu-lar disease that is not diabetic in origin. These conditions includeretinal emboli, choroidal nevi, age-related macular degeneration,hypertensive retinopathy, periorbital dermatological disease,cataract, and glaucoma. This poster reports the findings of nondi-abetic ocular disease using the JVN, suggesting the value of theJVN for managing eye disease in addition to diabetic retinopathy.

P4TELEHEALTH OUTREACH FOR UNIFIED COMMUNITYHEALTH (TOUCH)Dale C. Alverson, MD,1 Stan Saiki, MD2

1University of New Mexico School of Medicine, Albuquerque, NM;2University of Hawaii John A. Burns School of Medicine, Honolulu, HI

The Telehealth Outreach for Unified Community Health project,or TOUCH, is a proposed multi-year strategy to improve thequality of health care service and education in remote, multi-cultural areas in Hawaii and New Mexico. The Schools of Med-icine of these states, in collaboration with their rural hospital andtraining sites, including pilot sites at the Northern Navajo Med-ical Center and the Maui Community College, will employ tele-health technologies to serve the unique health care needs of theirisolated, culturally diverse populations. TOUCH teams health-care professionals, educators, librarians, and students work withcomputing scientists and engineers from the University of NewMexico’s high performance computing centers in Albuquerqueand Maui, to integrate advanced computing methods, includingvirtual reality. The collaboration will deploy a prototype systemfor enhanced applications in virtual collaborative distance learn-ing, education, training, patient care management, and problemsolving. This system utilizes the Access Grid, a technology thatprovides an environment where multiple users can all see, talkand hear, and share information, including 3-D models and im-ages, simultaneously over the Internet. The TOUCH approach ofcollaborative development between healthcare professionals andhigh performance computing scientists and engineers will serveas a model for training in other rural environments.

P5VIDEOPHONE USE BETWEEN A UNIVERSITY NICUAND RURAL COMMUNITY HOSPITALS: PARENTALSURVEY REGARDING THE IMPACTCindy Gyure, RN, CNNP, Virginia Laadt, PhD, Dale Alverson, MDUniversity of New Mexico Department of Pediatrics, Albuquerque, NM

Videophone (VP) technology which uses existing lower bandanalog communication infrastructure, standard touch-pad

phones and televisions provides a low cost solution for familiesin rural communities to see their newborn infant during hospi-talization in an often-distant tertiary care Newborn IntensiveCare Unit (NICU). A pilot program, “Mira Los Ninos,” was ini-tiated in the NICU at the University of New Mexico along withthree distant community hospitals. A study was conducted todetermine level of utilization, family satisfaction, and impact ofthe VP experience on the parent using retrospective phone in-terviews and a standardized survey tool. The number of fami-lies who used the VP compared to those who could have usedthe technology was lower than expected, 9/34 (27%). Overall sat-isfaction was very high. 86% felt it was equal to or better thanexpectations. 57% felt it decreased anxiety, and 57% stated it in-creased desire to be with their baby. All respondents would en-thusiastically encourage other families to use the VP. VP inter-action is a potentially cost effective means of enhancingcommunication with families who have infants in NICU. Strate-gies to provide adequate family promotion of VP availability andstaff training need to be implemented to increase effective uti-lization.

P6HIPAA AND THE MILITARY HEALTH SYSTEMArchie D. Andrews, MS,1 Lynn S. Crane, MS,1 Steve L. Packard,MS,2 Steve V. Pellissier, MS1

1Advanced Technology Institute, N. Charleston, SC; 2BWXT Y-12LLC, Oakridge, TN

An integral part of the Defense Healthcare Information Assur-ance Program is the examination of the advantages and disad-vantages of introducing information assurance technologies inthe medical treatment facilities. This examination is referred toas the Technical Business Case Analysis. To support this workthe analysis team developed a repeatable process that includesexamination of the suitability, benefits, risks, cost, and opera-tional impact of implementing information assurance technol-ogy. These factors are applied to the target technology in the con-text surrounding the operations of military medical treatmentfacilities. Technologies examined using the process include re-mote access dial-in user authentication, user authentication, ac-cess control, and auditing of access. This presentation will dis-cuss the methodology developed and refined by the analysisteam to support the analyses and a presentation of key findingsand recommendations from the business case analyses com-pleted to the date of the presentation.

P7THE OPERATIONAL USE AND CONSIDERATIONS OFREMOTE HEART RATE VARIABILITY DATAACQUISITION AND ANALYSISSuresh A. Atapattu, MSBE,1 Raul D. Mitrani, MD2

1University of Miami, Department of Biomedical Engineering, CoralGables, FL; 2University of Miami, Department of Cardiology, Miami,FL

We present the characteristics and results of the operational useof our computer program for the remote acquisition, analysis,and demographic database of patient data in clinical heart ratevariability research. Given the growing evidence that autonomicreflex alterations play an important role in many pathophysio-logical situations, heart rate variability (HRV) uses non-invasiveobservers to track the beat-to-beat modulation of the cardiac out-flow. The HRV of patients was determined from patient electro-cardiograms and shared with other physicians on line. The mainadvantage of this remote method is in the ability to cause mini-mum disruption or interaction with the patient thus avoiding ex-cessive autonomic responses. Also, the system integrates seam-lessly into the clinical environment with minimal, if any,disruption of the procedures related to patient care. This novel

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method uses the Lab VIEW programming environment to sim-plify and economically develop the remote communication fea-tures of our heart rate variability acquisition and analysis pro-gram. This online system was used to acquire the ECG of 30patients on-line and carry out the generation of the HRV indices.We successfully met our initial goal of remotely collecting ourpatient data and sharing it with our colleagues in the hospital inreal time.

P8BEST PRACTICES FOR HIGH UTILIZATION OFTELEMEDICINE†

David Bangert, PhDUniversity of Hawaii, Honolulu, HI

*No abstract available.

P9PAY PER VIEW: THE ARIZONA TELEMEDICINEPROGRAM’S BILLING RESULTSGail Barker, BA, Elizabeth A. Krupinski, PhD, Tammy Laursen,Kristine Erps, Ronald S. Weinstein, MDArizona Telemedicine Program, University of Arizona, Tucson, Ari-zona

This presentation describes the results of telemedicine billing andcollection activities of the Arizona Telemedicine Program. The pro-gram began billing for clinical services in January 1999. In prepa-ration, a letter was sent to all third-party payers in the state in-forming them of our intention to bill starting in January 1999. Sincethen 1,135 cases have been billed. We have done an analysis of thetelemedicine billing and collection activities and found that 47 in-dividual payers were invoiced. The payer mix was private insur-ance 29%, Medicaid/state programs 24%, Indian health service17%, Medicare/Champus 13%, self-pay 9%, and Department ofCorrections 8%. Since inception, $41,258 was billed to private pay-ers. $17,607 was collected which represents a 42.6% gross collec-tion rate (GCR.). This compares with the university’s physiciangroup practice GCR of 48.3%. In FY 99/00, the gross collection rateincreased to 48.2%. Due to the billing limitations imposed by theHealth Care Finance Administration, only four Medicare caseshave been billed to date. The State Medicaid program currentlypays only with authorization but is in the process of approving afull service contract. We concluded that after a start-up period,billing for telemedicine services parallels a traditional practice.

P10WINDOW’S ACTIVE DESKTOP: A TELEMEDICINECOMMUNICATION PORTALJim E. Barrett, EdD,1,2 Robert Brecht, PhD2

1University of Washington, Seattle, WA; 2E-Health Solutions, Inc.,Houston, TX

Providing a low-cost, easy-to-use-computer interface for busyhealth professionals has been a major barrier to the adoption oftelemedicine. This presentation will demonstrate how the TexasRural Hospital Telecommunication Alliance, a large ruraltelemedicine network of 50 hospitals, uses the Active Desktopfeature built into Microsoft’s Windows level operating systemsto provide easy, fast access to resources and for connections withother members of the network. The Active Desktop portal con-nects user to a customized collection of Internet Medical Re-sources, the user e-mail/group-ware application and a net-worked information and training site all within a single clickfrom turning the machine on. In addition, to these resources andtools the Alliance Desktop contains two active windows pro-viding critical information to every desktop requiring no actionon the part of the user. One window is dedicated to the an-nouncement of medical alerts, and the second serves as a com-

munication channel for news and information. Through this sys-tem Public Health emergency alerts can be pushed immediatelyto all member desktops. An unpublished report will be made onthe effectiveness of this desktop portal system in gathering re-search survey data and disseminating results.

P11OCULAR LOW VISION: ADVANCEMENTS ANDAPPLICATIONSWendall C. Bauman, Col, USAF, MC,1,2 Patricia A. D’Amore,PhD3,4

1Brooke Army Medical Center; 2Telemedicine & Advanced TechnologyResearch Center (TATRC), Fort Detrick, MD; 3Center for the AgingEye; 4Schepens Eye Research Institute

A collaborative, multi-disciplinary effort between the Center forResearch on the Aging Eye and the Department of Defense is ad-vancing research in low-vision, with direct applications to themilitary. Areas of interest include: Screening metrics to deter-mine tear film characteristics predictive of poor visual outcomesor complications for Laser in situ keratomileusis (LASIK)surgery. A portable imaging device permitting battlefield eval-uation of combat retinal injuries is being constructed. These im-ages will permit military ophthalmologists via telemedicine torecommend treatment options on/near the battlefield.

A demonstration that soluble fas ligand can be used to ma-nipulate neutrophil-mediated inflammation will be performed.This cellular manipulation has direct impact on corneal woundhealing from chemical burns or trauma. Human corneal en-dothelial cells transplanted in vitro can be grown to in vivo den-sities with comparable function. Methods to increase corneal en-dothelial cell density are being demonstrated. Optic nerveregeneration is possible using a retinal-brain co-culture systemusing lithium-containing antidepressants.

Using a mouse genetic approach, the role of vascular en-dothelial growth factor (VEGF) will be explored in adult angio-genesis. VEGF leads to loss of vision in diabetic retinopathy andmacular degeneration, common problems in the retired militaryand civilian communities.

P12DEVELOPING A COMPUTER-BASED PATIENT RECORDMAJ Catherine A. Beck, RHIA, MS,1 Mitra A. Rocca, MSc1,2

1United States Army Medical Research & Materiel Commmand (US-AMRMC), Telemedicine & Advanced Technology Research Center(TATRC), Fort Detrick, MD; 2AIM Laboratory, University of Pitts-burgh, Pittsburgh, PA

Whether healthcare is received in person or through telecom-munications, it must be documented. The paper record has donewell in the past, but it cannot keep pace with the advanced med-ical technologies used by today’s healthcare providers. Unfortu-nately, no computer-based patient record (CPR) has kept pacewith technology. Paper records and CPRs reside together inmany facilities. Many have learned that a CPR is not an easyproduct to develop or implement. The Medical InformaticsGroup at the Telemedicine and Advanced Technology ResearchCenter has developed a CPR for use as a research tool to test andfurther develop the use of voice/speech recognition, handwrit-ing recognition, natural language queries, information extrac-tion, and intelligent agents. Due to their products use with thePersonal Information Carrier (PIC), much feedback on the useand functionality of the software was obtained from multiplehealthcare providers using the product in different operationalsettings. The product’s ability to function with other advancedtechnologies and its ability to be utilized by multiple providersin multiple settings has provided great insight into the develop-ment and use of a CPR. The lessons learned from this researchtool can influence further development of the CPR.

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P13BIOMEDICAL ETHICS CONSULTATION ANDEDUCATION IN RURAL NEW MEXICO VIATELEMEDICINEDavid Bennehum, MD, Suzanne N. Shannon, Emily E. Freede,Dale C. Alverson, MDUniversity of New Mexico School of Medicine and Center for Tele-health, Albuquerque, NM

Members of the University of New Mexico Health Science Cen-ter Biomedical Ethics Committee (UNMHS-BMEC) have beenparticipating in a monthly consultation program via a telemed-icine link with the physicians working in a clinic for patients ofmodest means in Roswell, New Mexico, more than 200 milesfrom Albuquerque. As their facility had no Ethics Committee,the physicians in Roswell invited our committee to provide con-sultation and ethics education monthly for the past year over theTelemedicine network. The consulting HNMHSC-BMEC teamconsisted of two physicians, an internist, and a psychiatrist, apsychiatric nurse from the hospital consultation service, an at-torney, the Hospital Chaplain, and occasionally other membersof the committee. At the community clinic telemedicine site, theRoswell group would usually present one or more cases for dis-cussion, and occasionally the University group would presenttheir own case. The discussions were quite practical, but for eachcase it was attempted to extract principles and suggest relevantexamples, legal precedents, and useful readings in order to learnfrom each other. Family residents based in Roswell will also be-gin to participate as part of their rural community training. ThisBiomedical Ethics program represents another important appli-cation of Telemedicine serving rural communities.

P14USING TELEOPHTHALMOLOGY TO IMPROVERETINOPATHY SCREENING RATES AMONGCALIFORNIA AMERICAN INDIAN DIABETICSHeather Bernikoff, MS, Priscilla Enriquez, MPH, Bill Halverson,MScNE, MBACalifornia Telehealth & Telemedicine Center, Sacramento, CA

The California Telehealth & Telemedicine Center (CTTC) is us-ing telemedicine to increase access to ophthalmology specialtycare for California American Indian diabetics. In partnering withtechnical and cultural experts as well as the Indian Health Pro-gram, CTTC has developed a teleophthalmology grant programwith the goal of doubling the retinopathy screening rate amongIndian Health Program diabetics. The grant program providesfunding for the purchase of telemedicine equipment, staff train-ing, staffing, and some telecommunications. Case studies, im-plementation strategies, program design, and utilization infor-mation will be presented.

P15WEB-BASED PEDIATRIC HEART SOUND EDUCATIONOVER THE NEXT GENERATION INTERNETAlan E. Branigan, MA,1 Vivian L. West, RN, MBA,1 Michael E.McConnell, MD2

1The Telemedicine Center, Brody School of Medicine, East CarolinaUniversity, Greenville, NC; 2Department of Pediatrics, Emory Uni-versity School of Medicine, Atlanta, GA

An online educational application has been developed for edu-cating pre-practice health professionals about pediatric heartsounds. The application incorporates a very user friendly simu-lated patient interface with high fidelity digitally recorded heartsounds, supporting didactic text, illustrations, and a self-assess-ment. Instead of hearing just one representative heart sound, theuser can listen to four sounds that correspond to the four chestlocations most commonly auscultated, thus more closely simu-lating an actual examination.

Originally developed for CD-ROM delivery, the applicationhas been ported to a Web interface and delivery via the NextGeneration Internet, with funding from the National Library ofMedicine. We are also expanding the application to include car-diac ultrasounds. A port of the application to the commodity In-ternet, with preservation of the high sound fidelity, is also beingexplored.

One of the objectives of this project is to determine if the ap-plication can improve auscultation skills. Research indicates thatmedical students and residents have poor cardiac auscultationskills, with lack of formal training and assessment in medicalschools being one contributing factor. Accessibility for trainingvia the Web may help students attain a higher level of pediatriccardiology auscultation skills than is currently being achieved.

P16TELEMEDICINE ASSISTANCE CENTER: TAKINGTELEMEDICINE TO THE PHYSICIAN’S OFFICESamuel G. Burgiss, PhD, Gary T. Smith, MD, David Black, BSUniversity of Tennessee Medical Center, Knoxville, TN

When the typical telemedicine barriers of reimbursement and li-censure are removed, the remaining barrier is the impact on thephysician or other provider to go to a central location for patientconsultations. A method has been developed and is being usedto provide interactive video conferencing to a virtual exam roomin the physician’s office while maintaining support that wouldtypically be available at a central telemedicine location. TheTelemedicine Assistance Center (TAC) supports consultationsbetween physicians and other providers, and their patients atspoke telemedicine sites. A nurse at the TAC can connect anyspoke site of any bandwidth (T-1 ISDN, or POTS) with aprovider’s office at full received bandwidth. In this virtual clin-ical environment, the TAC nurse can communicate with the pa-tient and presenting nurse, the provider, or both to create a sup-port function as if all were in the same room. Facilities areprovided to switch from one patient room to another regardlessof the bandwidth, to connect the provider’s room with the pa-tient’s room when both are ready, and for the TAC nurse to sup-port this process in a manner that is considerate of the needs ofboth the patient and the provider.

P17PROGRAM SATISFACTION AMONG RURALARKANSAS ADOLESCENTS IN A CONSUMER HEALTHEDUCATION PROGRAM USING INTERACTIVE VIDEOAnn B. Bynum, EdD,1 Cathy A. Irwin, PhD, RNP,1 George S.Denny, PhD2

1University of Arkansas for Medical Sciences, Little Rock, AR; 2Uni-versity of Arkansas, Fayetteville, AR

Socioeconomic and demographic factors can affect the impact oftelehealth education programs that utilize interactive video tech-nologies. This study assessed program satisfaction among partic-ipants in the Arkansas School Consumer Health Education Pro-gram that uses interactive compressed video. Variables in theone-group posttest study were age, gender, ethnicity, education,community size, and program topics for years 1997–1999. The con-venience sample included 3,319 participants in junior high andhigh schools. Adolescents had high levels of satisfaction regard-ing program interest and quality. There was significantly highersatisfaction for programs on muscular dystrophy, anatomy of theheart, biology of the skin, tobacco addiction, and heart dissection(p � 0.001 to p � 0.008). Females, nonwhites, African Americans,and junior high school students had significantly greater satisfac-tion (p � 0.001 to p � 0.005). High school students had signifi-cantly greater satisfaction with the interactive video equipment(p � 0.011). White females (p � 0.025) and African Americanmales (p � 0.004) in smaller communities reported higher satis-

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faction. Findings from the study can be used to improve schooltelehealth education programs by focusing on increased access inrural areas among ethnic groups, participant’s learning needs,speaker communication, and clarity of program presentation.

P18REMOTE INTERACTIVE MONITORING OF PATIENTSON ANTICOAGULATION THERAPY TO IMPROVEOUTCOME AND AVOID COMPLICATIONSJennifer L. Calagan, PhD, MD, Sewnet Mamo Dr.PH candidate,Thomas R. Bigott, Daisy T. DeWitt, MS, Marina N. Vernalis, DOWalter Reed Army Medical Center (WRAMC), Washington, DC

Background: Coumadin is used to regulate the clotting times ofmany cardiac patients. Regulating Coumadin dosages requiresclose monitoring of the patient’s clotting times. This monitoringrequires regular clinical visits and tracking. We are assessing theuse of remote testing and monitoring of Coumadin patients us-ing telemedicine technology.

Method: 400 patients are equally divided into four groups. Theprotocol for the groups include:

1) Home measurement of INR and standard assessment2) Hospital INR testing and home patient assessment, and3) Home INR measurement and home patient case assessment.4) These three groups will be compared to a control group that

receive standard care.

Results: The following parameters are monitored: 1) Qualityof care as assessed by: Reduced ER visits, morbidity, mortality,2) Access to care as provided by daily monitoring and interven-tion, 3) Acceptance of Care/Patient Satisfaction, and 4) Cost(Travel, Lab Tests, Provider Time, ER Visits)

Conclusion: Project will assess the use of a programmablehome-monitoring system in association with home testing to al-low patients to report changes in condition, problems with ther-apy, and complications. It is expected that the increased moni-toring will enhance the practitioner’s ability to optimize therapyand track, if not avert, complications.

P19BRINGING HEALTHCARE IN THE DEPARTMENT OFDEFENSE INTO THE 21ST CENTURYCol. Dean E. Calcagni, MDUnited States Army Medical Research & Materiel Command (US-AMRMC), Telemedicine & Advanced Technology Research Center(TATRC), Ft. Detrick, MD

The U. S. Army Medical Research and Materiel Command hasbeen exploring and implementing telemedicine and other med-ical advanced technology solutions for over 10 years. TheTelemedicine and Advanced Technology Research Center(TATRC), a component of the U.S. Army Medical Research andMateriel Command, is where these solutions are being created.

In order to take advantage of rapidly evolving technologies,TATRC uses a rapid prototyping model to develop telemedicineand medical advanced technology products. In this model, tech-nologies are identified, and systems are assembled. They aretechnically tested and modified based on clinical requirements.These systems are tested operationally and then given to actualdeployed medical units to augment their medical care capabil-ity. The whole process from identification of technologies tofielding of tested systems can be as short as a few months.

In the past 5 years TATRC has deployed telemedicine capa-bilities with U.S. military medical units in support of operationsworldwide.

This presentation will explain the TATRC approach towarddemonstrating and inserting medical advanced technology intothe health care delivery system of the Department of Defenseand will give an overview of several current TATRC projects.

P20FLATLAND, A TOOL FOR THE CREATION OF VIRTUALTELE-ENVIRONMENTS FOR INTEGRATED TELEHEALTHAPPLICATIONSThomas P. Caudell, PhD, Ken Summers, John Greenfield, BobBallance, PhD, Holly Buchanan, PhD, Dale Alverson, Saiki S.University of New Mexico, Albuquerque, NM

Flatland is an open visualization/virtual reality application devel-opment tool created at the University of New Mexico. Flatland isone of the core software components of the University of New Mex-ico TOUCH Project (Telehealth Outreach for Unified CommunityHealth). It allows software authors to construct and users to inter-act with arbitrarily complex graphical and aural representations ofscientific data sets and complex software systems in a distributedmanner. Flatland is open software that is written in C/C�� anduses the standard OpenGL graphics language extensions to pro-duce the 3D graphics. In addition, Flatland supports any type ofdisplay technology. Flatland is multithreaded and uses dynami-cally linked libraries (DLL) to load applications that construct ormodify its virtual environment (VE). In addition, Flatland runs inparallel on Linux clusters, and is interactive over the NSF AccessGrid allowing users at multiple remote sites to participate in col-laborative sessions. This talk will give an overview of the featuresof Flatland, give examples of the application of Flatland to tele-health, and discuss current research issues.

P21ANTICIPATORY GUIDANCE AS A FRAMEWORK FORIMPLEMENTING A REHABILITATION TELEMEDICINEPROGRAMCathy M. Ceccio, MSN, CRRN, CNAA, Mary Jo Roach, PhD,Denise Forster-Paulsen, MSN, CRRN, ANP, Kathleen Murany,RN, CRRNThe MetroHealth System/MetroHealth Center for Rehabilitation,Cleveland, OH

The use of anticipatory guidance is a well-known strategy in clin-ical practice to help persons cope effectively with issues that af-fect health and well-being. At MetroHealth Center for Rehabili-tation, anticipatory guidance was used as a framework to directthe implementation of the telemedicine program for persons withacute, complex injuries. Since patients at this institution had gen-erally had little experience with any type of technology pre-in-jury, staff determined that developing an appreciation for tech-nology was critical to the success and future use of telemedicine.Using vignettes and case discussions, clinicians from several dis-ciplines conducted telemedicine visits, with ten clients and fam-ilies in the on-site transitional living apartment one week beforedischarge. Clients were asked to envision the use of telemedi-cine in their home and to articulate one aspect about the tech-nology that might be useful to them after discharge. Clinicianswho conducted the interviews expressed no specific expectationsthat clients agree to telemedicine visits after discharge. Case re-ports will be used to describe the encounters and to highlight in-dividuals’ abilities to participate in and articulate the usefulnessof telemedicine technology in their lives after discharge.

P22IN-HOME TELEMEDICINE MONITORING OFPEDIATRIC PATIENTS WITH ASTHMA USING STOREAND FORWARD TECHNOLOGYDebora S. Chan, RPh, FASHP, Francis J. Malone, MD, CharlesW. Callahan, DODepartment of the Army, Department of Pediatrics, Tripler Army Med-ical Center, Honolulu, HI

Objectives: The purpose of this project is to demonstrate the feasi-bility of in-home asthma monitoring for children with persistentasthma using Internet-based store and forward technology.

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Methods: Ten patients between 6 and 17 years of age with mildpersistent, moderate or severe asthma will be enrolled into a pi-lot “virtual” study group. Asthma education and case manage-ment will be provided for 6-months. Adherence will be assessedby therapeutic and diagnostic monitoring. Therapeutic monitor-ing parameters include video of patient using MDI � spacer tech-nique submitted electronically two times a week using in-homeasthma monitoring store and forward technology. Diagnosticmonitoring will include asthma symptom diary and video ofpeak flow use submitted electronically. Parameters used to as-sess disease control include lung function tests, quality of lifetests, utilization of services, rescue therapy use, symptom con-trol, satisfaction, and asthma knowledge retention. The pilotstudy will also include evaluation and development of software,cameras, and computer systems, as well as the optimal way forpatients to record MDI � spacer technique and peak flow mea-surement using the Internet.

Conclusion: This pilot will serve as the first step for a con-trolled trial using Internet store and forward technology for casemanagement of pediatric asthma.

P23SHRINERS PACIFIC TELEMEDICINE PROJECT:PROVIDING PEDIATRIC ORTHOPAEDIC CARE VIATELEMEDICINEKent Reinker, MD, Jana Chang, RNShriners Hospitals for Children, Honolulu, HI

The patient base of the Shriners Hospitals for Children—Hon-olulu extends throughout the Pacific Ocean, encompassing anarea of over 1.2 million square kilometers. Since 1999, the hos-pital has been involved in a telemedicine outreach programwhose primary purpose is to provide specialty and subspecialtymedical care to children in the geographically isolated island na-tions of the Pacific.

Methods: We have utilized video conferencing to those areaswith adequate far end capabilities. The Honolulu Shriners hos-pital has instituted regular consultation clinics with practition-ers in Guam and American Samoa, and have recently alsoachieved teleconference connections with Palau. During the nextyear, we expect to establish linkage with the Federated States ofMicronesia as well. In areas without real time conferencing ca-pabilities, we have utilized store and forward techniques.

Results: Patients and families who have received care viatelemedicine have been happy with the results. In many in-stances, alternative methods of providing consultation wouldhave been impossible. Other patients and families have dramat-ically saved on travel time and costs.

We have encountered two broad classes of problems. Tech-nological problems have related primarily to the limitations ofbandwidth. Licensure, credentialling, and patient privacy werethe major administrative problems.

P24UTILIZING TELEMEDICINE CONCEPTS AND PROBLEMBASED LEARNING IN THE TEACHING OF BREASTCANCER DISEASESpyros G. Condos, MD, MBA, Chrysoula Toli, MD, TelemahosStamkopoulos, PhDYale Office of Telemedicine, Yale School of Medicine, New Haven, CT

Today countless Medical Schools around the world are usingProblem Based Learning (PBL) methodology in their programsvery successfully. At the same time Telemedicine concepts havebeen recognized as a very important tool in Medical Educationand Distance Learning.

We incorporated PBL and Telemedicine concepts (multime-dia systems, telecommunication technologies and databases) and

we developed a Web-Based, PBL model of Learning to teach theClinical Pathway of the Breast Cancer Disease (BCD).

We choose to apply this model to the BCD, because of its com-plexity and comprehensiveness. To that extent we developed aClinical Pathway of the BCD, inclusive of screening, projection,early detection, treatment, follow up and clinical trials.

The model was intended to be used, by patients, medical stu-dents, nurses, residents, primary care physicians and other prac-titioners.

The effectiveness of the model was tested on two medical stu-dents over a period of two months and it was proven to be highlysuccessful, user friendly, and easy to follow.

We have thus developed an alternative to the various Con-tinuing Medical Education programs that use passive lecture-based activities.

In addition we allow the physician to develop the skill of self-directed learning, an ideal ingredient for Distance Learning.

P25FEASIBILITY OF IN-HOME TELEHEALTH FORCONDUCTING RESEARCHCarol E. Smith, PhD, RN,1 Jennifer J. Smitka, RN, BSN,1 SusanV.M. Kleinbeck, RN, PhD, CNOR,1 Faye Clements, RNC,2 DavidCook, PhD1

1University of Kansas Medical Center (KUMC), Kansas City, KS;2Skilled Nursing Facility, Topeka, KS

The purpose of this study was to determine the feasibility of us-ing in-home audio/video telehealth equipment for administer-ing nursing interventions to families and collecting research dataover time. The study design was descriptive with observationdata collection and comparison. The subjects were adult patients(n � 5) that were monitored using nighttime equipment pro-vided by their caregivers (n � 7) for home care. Skin color, vitalsigns, spirometery, and pulse oximetry and observation of care-giver and patient equipment were reliably obtained. Nursing in-terventions, equipment demonstrations, visual illustrations, ed-ucational videotapes, and audiotape directions were transmittedclearly across telehealth, with the exception of materials that hadlow contrast in color or small font size. Costs of telehealth homemonitoring for data collection were less expensive than tradi-tional data collection via home visits. In-home telehealth trans-mission via residence telephone lines was reliable for deliveringeducational nursing interventions and for collecting physiologi-cal as well as observational data.

P26RESEARCH APPROACHES TO ESTABLISHINGTELEMEDICINE EFFICACY FROM A COMMUNICATIONSTUDIES STANDPOINTDavid Cook, PhD, Pamela Shaw, MD, Eve-Lynn Nelson, MACenter For TeleMedicine and TeleHealth, University of Kansas Med-ical Center (KUMC), Kansas City, KS

This project assesses parent satisfaction with an interactive tele-video visit with the parent satisfaction with face-to-face visitswith the same pediatrician. The questionnaire addresses itemsspecific to parent-physician communication. The face-to-faceand ITV parents did not significantly differ on the collected de-mographic items. Face-to-face questionnaires were comparedwith telemedicine consultations with the same pediatrician. Thepreliminary results suggest that the two settings do not differsignificantly in parent evaluation. This suggests that the pedi-atrician is as effective in establishing a relationship with theparent over ITV as in person. This is an important question bothin terms of supporting the physician’s ability to establish diag-nosis based on history and his/her influence on adherence andfollow-up.

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P27SMART CARDS AND HEALTHCARE IN THE 21ST

CENTURYDiane Corcoran, RN, PhD,1 Ruth Anderson, RN, PhD2

1Kelly Anderson & Associates, Alexandria, VA; 2Duke University,Durham NC

Smart card technology is about to emerge as a major solution tomany of the problems currently faced in health care. At a mini-mum, smart cards will help with security, HIPAA compliance,efficiency, patient safety and privacy, security in the transfer ofmedical data, accuracy of documentation, access to emergencymedical data and overall quality of care. In this presentation, thepresenter will describe the technology, its capabilities, and po-tential uses. In addition, she will describe current Governmentand private sector programs that are using the technology.

P28DESIGNING A TELEHEALTH BUSINESS DEVELOPMENTPLAN: WHO? WHAT? WHERE? WHY? AND HOW?Jolene A. Davidson, PT, MPT, Mark Hakel, PhD, CCC-SLPMadonna Rehabilitation Hospital, Lincoln, NE

Whether beginning a telehealth program or expanding an exist-ing one, a sound business development plan is essential in cre-ating a successful program. It is suggested that programs andprojects should have a design/planning component that docu-ments the purpose, need and feasibility. This will insure thatthose involved in implementing the program and individualspromoting the program have fine-tuned the service and will de-liver a high quality, cost effective product.

This presentation presents a model on how to develop a suc-cessful business plan that addresses the purpose, need and feasi-bility. Key variables that are necessary in making a financially vi-able plan will be presented. These variables include discussion onthe need for creation of a vision and mission to guide the devel-opment of the program. In addition, strategies will be presentedon how analyze the target market and need, meet regulatoryguidelines (e.g., HIPPA compliance, third party payers) and strate-gies to examine the success of your program. A sample businessplan will be used to illustrate the implementation of this model.

P29WHAT DO PATIENTS THINK OF TELEHOMECARE?George Demiris, PhD, Stuart M. Speedie, PhD, Stanley M. Finkel-stein, PhDDepartment of Laboratory Medicine and Pathology, Medical School,University of Minnesota, Minneapolis, MN

The objective was to measure patients’ perceptions of a tele-homecare system before and after participation in order to de-termine a possible change and identify the system’s features thatpatients perceived differently. The setting was the TeleHome-Care Project, which utilizes videoconferencing and Internetequipment to enable interactions between patients and nurses.

Patients viewed videotape that demonstrates a “virtual homevisit” and filled out a questionnaire that measures perceptions oftelehomecare (pre-test). They were then randomly assigned to acontrol group receiving standard care or to an experimental groupreceiving in addition videoconferencing sessions. Both groups filledout the questionnaire again when exiting the system (post-test).

The control group consisted of 11 and the experimental groupof 17 patients. There was no statistically significant perceptionchange for the control group. The experimental group showed anoverall more positive perception after their experience (total scoreincrease by 6.06, P � 0.0001). Patients evaluated their experienceas positive, felt comfortable with the technology, and convincedthat a nurse can assess their status over the television; however,

there was less agreement with the statement that telehomecaresaves them time. The findings indicate that telehomecare has thepotential of a widely acceptable care delivery mode.

P30DIFFERENCES IN COMMUNICATION MODE IN AHOME TELEHEALTH PROJECT FOR DIABETICSSusan L. Dimmick, PhD,1 Samuel G. Burgiss, PhD,2 Sherry Rob-bins, RN3

1University of Tennessee Graduate School of Medicine, Knoxville, TN;2University of Tennessee Medical Center, Knoxville, TN; 3Telemedi-cine Manager, Scott County Telemedicine, Knoxville, TN

Data from 32 diabetics in a rural county in East Tennessee wereanalyzed to determine the potential impact of weekly two-wayvideo telemedicine consults versus weekly telephone calls on pa-tient compliance and HgA1C readings over time. Study partici-pants used a digital blood sugar monitoring unit at home to sendregular blood sugar readings through their plain old telephonesystem (POTS). Half of the patients had video consults at homewith registered nurses. Half had a telephone call at home fromregistered nurses that did not include two-way video. Bench-mark data for the diabetics included before and after HgbA1Creadings in addition to body mass index, functional capacity, de-mographics and quality of life rankings. Hospitalizations, in-cluding emergency department use for the complications of di-abetes or diabetes symptoms, were benchmarked as well. Datawere analyzed before and after the home telemedicine interven-tion to determine the impact of video versus non-video nursefollow-up contact and its potential impact on clinical outcomes.

P31PEER REVIEW IN A TELEDERMATOLOGY SERVICEAngela Dingbaum, RN, MPH, William P. Bowman, Jr., AD,Daniel T. Summers, BSUnited States Army, Center for Total Access, Ft Gordon, GA

Policy and peer review activities must be instituted for anyhealthcare delivery model that is incorporated into the businessprocess of a medical facility, teleconsultation or otherwise. Theseactivities ensure that the service complies with accepted stan-dards that monitor clinical practice, clinical privileges, image se-curity, informed consent and documentation.

The Center for Total Access, or CTA, has had oversight of theimplementation a regional store and forward web-based Teled-ermatology program for the military since May 1, 1999. Thereare seven consulting sites and seventeen referring sites that havegenerated over four hundred consults since inception.

A peer review program has been developed by the CTA asan enhancement to the regional Teledermatology service. Everymonth, as single consult will be selected, stripped of identifyinginformation, and distributed to an established peer-review net-work of dermatologists. Each specialist assesses the consult withregard to image quality and appropriateness, adequate historyand physical information, supportive information for diagnosisand recommendation, consistency with standards and an over-all rating. Implementation of a peer review process marks theevolution of a teleconsultation project from a pilot study into aformalized standard of care for the military healthcare system.

P32EVALUATION OF TELECONSULTATION FORVETERANS WITH SPINAL CORD IMPAIRMENT INCOMMUNITY SETTINGSLaureen Doloresco, MN, RN, CNAA, Susan Thomason, MN, RN,CS, Judy Trotman, RN, BSN, Diana Weinel, MSN, RNSpinal Cord Injury/Disorder Service, James A. Haley Veterans’ Hos-pital Tampa, FL

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An offshoot of the telemedicine explosion, teleconsultationpromises to be a 21st century phenomenon. Teleconsultationlinks a major SCI/D specialty referral center to non-specialtyhealthcare facilities, e.g., outpatient clinics.

An evaluation of a one-year statewide teleconsultationdemonstration project was conducted by the SCI/D Service atJames A. Haley Veterans’ Hospital from July ‘99 to July ‘00.Telemedicine units were placed in six VHA satellite outpatientclinics in Florida and linked to the Tampa VA SCI/D Service.

Twelve clients participated in this evaluation. Although mostteleconsultation visits were initiated for pressure ulcer manage-ment, other visits involved teleconsultation for functional eval-uation, medication management, urinary tract infections, andother conditions. Three hospital admissions and two rehabilita-tion admissions were arranged following teleconsultation.

Outcomes included healthcare provider and client satisfac-tion. Benefits and barriers to teleconsultation were identified.

Effective telecommunication linked clinical care, education,and administrative systems to ensure client and professional ac-cessibility to specialized SCI/D resources.

Teleconsultation did not replace on-site clinical examinationby a trained practitioner, but was an adjunctive tool for care de-livery for outpatients with SCI/D.

P33RESEARCH APPROACHES TO ESTABLISHINGTELEMEDICINE EFFICACY IN A PEDIATRIC SETTINGPamela Shaw, MD, Gary C. Doolittle, MD, David Cook, PhD,Deborah Swirczynski, MA, Eve-Lynn Nelson, MACenter For TeleMedicine and TeleHealth, University of Kansas MedicalCenter (KUMC), Kansas City, KS

This presentation will describe the implementation of an efficacystudy comparing face-to-face evaluation and ITV evaluation ofthe same patient by two pediatricians. Twenty elementary-agechildren were evaluated over 128 kb/s ISDN technology withotoscope and stethoscope capabilities and face-to-face in theschool nurses office. The pediatricians were randomized to ei-ther face-to-face or ITV evaluation for a particular patient. Thepaper will address implementation issues, including recruitmentand the human subjects processes. The interrater reliability willbe presented as well as design issues. The presenter will sum-marize what is lost and what is gained in the pediatric evalua-tion over telemedicine in comparison to the face-to-face acutecare exam. This includes both physical exam issues, such as colordetection and hearing heart/lung sounds, as well as history tak-ing issues such as abuse history.

P34AN ANALYSIS OF THE SUITABILITY OF TELEMEDICINETO PROVIDE HOSPICE CAREGary C. Doolittle, MD,1 Michael McCartney, BS,1 Pamela Whit-ten, PhD,2 David Cook, PhD1

1Center For TeleMedicine and TeleHealth, University of Kansas Med-ical Center (KUMC), Kansas City, KS; 2Michigan State University,East Lansing, MI

Telehospice® is the use of telemedicine technology to enhanceend-of-life care. One year ago, a bi-state project was launched tostudy the use of home-based telemedicine for routine hospiceservices. Home based telemedicine units (ViaTV, 8 � 8 Inc., SantaClara, CA) were deployed for electronic nursing visits and eval-uations by social workers. In order to determine what propor-tion of home hospice visits could be performed using currentlyavailable telemedicine technology, we retrospectively reviewedclinical records for hospice nurse home visits. Clinical notes wereobtained from two large hospices (one based in Kansas and onein Michigan). Records were randomly sampled for patients who

received hospice nursing visits during the month of January 2000.The charts were reviewed for patient demographic information,patient assessments, teaching activities, and interventions. Fivehundred ninety-three hospice nursing visit notes were analyzedusing an 85-item coding instrument. After careful record review,the observers also made a subjective observation regarding thesuitability of each visit for telemedicine. For 61% of these visits,telemedicine could reasonably have replaced the on-site visit. Wefound that a significant proportion of home hospice nursing vis-its could be performed using telemedicine, with the potential tosignificantly reduce the cost of providing hospice care.

P35RESEARCH APPROACHES TO ESTABLISHINGTELEMEDICINE EFFICACY IN A CHILD PSYCHIATRYSETTINGDavid Ermer, MD,1 Eve-Lynn Nelson, MA,2 Sharon Cain, MD2

1University of South Dakota School of Medicine, Sioux Falls, SD; 2Cen-ter For TeleMedicine and TeleHealth, University of Kansas MedicalCenter (KUMC), Kansas City, KS

*No abstract available.

P36VIRTUAL PRIMARY CARE CLINICGregory A. Gahm, PhD, Nhan Do, MDMadigan Army Medical Center, Tacoma, WA

The Virtual Primary Care Clinic is a web based e-health researchinitiative designed to improve access to, and quality of, carewhile simultaneously controlling costs. Specifically, this projectprovides patients a secure web site with on-line appointing(booking, reviewing current appointments, cancellation of ap-pointments), review of medication, laboratory, and radiology re-sults, and asynchronous secure communication with providers.It targets health promotion and prevention through directedhealth information delivery, on-line access to health information,on-line home health monitoring and on-screen graphing, andprovider profiling of patients by disease state and clinical needs.It includes specific measurement of total costs of this process toinclude provider time requirements, impact on workload ac-counting, and effects on overall healthcare system usage. Costcontainment is a goal through appropriate provider level usage(nurses and paraprofessionals when appropriate to handle theinformation) and targeting high cost/frequency system users.

P37JOSLIN VISION NETWORK (JVN): THE ARCHITECTUREOF JVN-2W. Kelley Gardner, Sven-Erik Bursell, PhDJoslin Vision Network Research Team, Beetham Eye Institute, JoslinDiabetes Center, Boston, MA

The Joslin Vision Network (JVN) is a telemedicine platform de-signed to facilitate increased access of diabetic patients into aprogram of annual eye care. The JVN provides remote point ofcare imaging of the retina with centralized resources to providethe assessment of retinopathy and a suggested treatment plan.A technological drawback to the prior JVN implementation in-volved a reliance on relatively proprietary hardware and soft-ware technologies, making the system difficult and expensive todeploy and maintain. These limitations drove the developmentof a platform that relies on commercially-off-the-shelf (COTS)technologies and software applications. The server platform usesPACS products from Agfa and Mitra including the IMPAX Basiximage archive server, Web 1000 web server, and the Broker in-terface engine. This is a robust environment providing the re-quired DICOM compliancy and HL7 interfaces to facilitate in-teraction with existing hospital information systems. New client

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applications for image acquisition and display, designed specif-ically for retinal imaging, were developed on the Windows 2000platform using this PACS environment. This presentation de-scribes system architecture and application specific features arepresented as well as issues involved with developing a retinalimaging application on a system platform originally designed foruse in radiology.

P38FROM TELEMEDICINE TO REFERRALS AND ASP’SDISTRIBUTED MEDICAL CASE-NOTE MANAGEMENT ON THE INTERNETMark Gillett, MB, MIDireHealthEngines Inc., Cambridge, MA

Over the last decade, communications and data processing haveevolved beyond all predictions. Computing power has movedfrom the data-center (mainframe) to the department (mini) andfrom the host to the desktop and now with the arrival of the In-ternet is moving back to the commercial data-center within newApplication Service Providers (ASP).

In many applications, green-screens have given way to a be-wildering choice of client-server GUI’s and the same trend to-ward distributed computing has empowered users and changedbusiness practices. Serial connections to hosts have given way to1st generation networking protocols and early fixed and dialupnetworking infrastructures that have in turn been eclipsed byTCP/IP and the Internet. In Telemedicine, slowly a reliance oninteractive video has given way to an emerging requirement forsolid, legally referenceable consultation records, while applica-tions have moved from specialized workstation to the desktopand more recently to the appliance enabled web.

In the main however; outside of large academic institutions,providers have been slow to adopt these new technologies. Withthe mainstream arrival of the Internet and its accompanying ben-efits, eReferrals may be set to leapfrog recent reforms andchanges in practice to become a significant economic and clini-cal force in the healthcare environment.

The face of medicine will change as clinical communicationmoves out of its infancy to deliver distributed, multimedia en-abled medical records; common, shared and distributed betweenPhysicians, Laboratories, Imaging Centers, Pharmacies and Pa-tients. In this endeavor, Telematics, EPR, Clinical Data Ware-housing, Data Mining will come together to drive a new para-digm. Electronic information is now geographically unboundedenabling clinical and organizational boundaries to be crossedfrom any Internet enabled device. These changes are facilitatinga broader continuity in healthcare, increased quality of care andever decreasing cost.

P39TELEMEDICINE PRECEPTING—PRACTICALITY,FEASIBILITY, ACCEPTABILITY, AND RELIABILITYKimberly A. Goodemote, MD, Floyd B. Willis, MDMayo Clinic Family Medicine, Jacksonville, FL

Telemedicine is rapidly becoming a valuable tool to enhance andcomplement health care services. There are several studies oncommunication with patients via telemedicine. Further studiesare needed, however, on the evaluation of the patient, deter-mining diagnoses, and developing management strategies. AtMayo Clinic in Jacksonville, FL, several studies have been doneor are being developed to study the various aspects of evalua-tion and treatment of the patient by telemedicine. Many of thesestudies have been developed within the Family Medicine De-partment, which also contains a residency program. The FamilyMedicine Residency Program staffs an indigent clinic in Jack-sonville. Precepting is required for all residents that staff the

clinic. The precepting is currently done on site. This study wasdeveloped to determine the practicality, feasibility, acceptabilityand reliability of telemedicine precepting. At the completion ofthis study, the expection is that telemedicine precepting is an ad-equate and accurate method of supervising residents in an effi-cient, cost effective manner.

P40THE PREPAREDNESS OF PENNSYLVANIA EMERGENCYDEPARTMENTS TO EVALUATE AND TREAT VICTIMSOF BIO-CHEMICAL TERRORISMMichael I. Greenberg, MD, MPH, FAAEM,1 Sherri Jurgens, MPH2

1MCP-Hahnemann University, Department of Emergency Medicine,Philadelphia, PA; 2MCP-Hahnemann University, Philadelphia, PA

Objectives: To determine the state of readiness of all hospitalemergency departments (EDs) in the state of Pennsylvania toevaluate and treat casualties from terrorist use of biologicaland/or chemical weapons.

Methods: A written survey instrument (coded and blinded) in-tended to assess 38 key points referable to emergency depart-ment preparedness was developed and mailed to the physiciandirector of every emergency department (n � 202) in Pennsyl-vania. Results were entered into a computer database and wereanalyzed using SPSS software.

Results: The response rate for this study was 69%. The ma-jority (84%) of ED’s surveyed had no biological or chemical threatagent detection devices available and over 90% did not stock ap-propriate antidotes needed to treat these casualties. Data re-vealed an absence of formal training, substantial deficiencies inthe ability to decontaminate patients, as well as a lack of coop-erative agreements between hospitals and local and federal emer-gency and public health agencies.

Conclusions: This study is the first comprehensive evaluationof emergency department preparedness regarding bio-chemicalterrorist threats in a US state. Substantial gaps exist in the cur-rent level of ED preparedness in Pennsylvania hospitals. As a re-sult, a comprehensive plan for correcting these deficiencies needsto be developed and implemented promptly.

P41TELEREHABILITATION FOR THE REMOTEASSESSMENT OF PRESSURE ULCERS IN INDIVIDUALSWITH SPINAL CORD INJURY: A PRELIMINARY REPORTLauro Halstead, MD, Tom Dang, MSE, Mathew Elrod, PT, MEd,Steven Woods, BA, Rafael Convit, MD, Michael Rosen, PhDNational Rehabiltation Hospital, Washington, DC

Pressure ulcers represent a major, lifelong health hazard for per-sons with spinal cord injury (SCI). This health risk is increasedwhen the individual lives in a rural area with inaccessible or non-specialized health care. The goal of this project is to address thisneed by demonstrating that teleassessment of pressure ulcers in aremote setting is comparable to assessments made in a specialtyclinic. In a pilot study, 20 pressure ulcers were assessed in indi-viduals with SCI in a wound clinic in a metropolitan rehabilita-tion hospital. Images of each ulcer were obtained using a digitalcamera and forwarded to a computer monitor in a separate loca-tion. A Wound Care Specialist (WCS: a plastic surgeon) completeda questionnaire concerning his “remote” assessment of the woundand treatment recommendations with the option of live video in-teraction. Using the same questionnaire, then WCS assessed thewound live. A comparison of the two assessment methods showed60–90% agreement concerning treatment recommendations, theneed for referral, and overall satisfaction with teleassessment.Based on our experience with this pilot study, we will discuss thepros and cons of teleassessment for wound management and plansfor field-testing in remote settings.

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P42CONSTRUCTING A TELEMEDICINE INFORMATIONPORTALEric Hanson, MBAUnited States Army Medical Research & Materiel Command (US-AMRMC), Telemedicine & Advanced Technology Research Center(TATRC), Ft. Detrick, MD

The presenter will articulate the need for an XML-based method-ology to describe and communicate information about telemed-icine projects and news information required to create an infor-mation Portal. The Portal will serve as a central informationlocation for the telemedicine community linking disparate re-sources from across the Web into one cohesive interface. The pre-sentation will define the open source system and Open ContentSyndication (OCS) architecture required to make the proposedPortal successful. OCS is used to mark-up Web pages so that asoftware engine can collect the data elements and present themto a user through the Portal. Users of the Portal can then readthe summary text and drill-down to the actual content. The Por-tal provides the news aggregation and organization interface thatenables the user to customize their experience. An implementa-tion plan will be unveiled and concrete action items will be gen-erated in an interactive discussion to achieve buy-in from thecommunity.

P43DELIVERING HOME-BASED CARE: EVIDENCE-BASEDPRACTICE AND A BEST-FIT APPROACHRoxanne Pickett Hauber, PhD, RN, CNRNShepherd Center, Atlanta, GA

Disabilities resulting from catastrophic injury or disease are lifealtering. Individuals and their families, dealing with disabilities,face life-long changes in physical and/or cognitive abilities, vo-cational goals, social roles and other basic aspects of life. Healthcare reform has resulted in significant reductions in lengths ofstay in rehabilitation settings, as well as in the availability of long-term services and support. Technological developments thatbridge geographic distances, as well as other barriers, offer newpossibilities for meeting this challenge. Since 1995, ShepherdCenter in Atlanta, GA has been engaged in research and devel-opment of effective and efficient ways to use telecommunicationstechnology to extend the continuum of care after discharge frominpatient rehabilitation. In an environment of rapidly changingtechnologies and increasing market demands, Shepherd uses anevidence-based practice and “best- fit” approach to it’s use ofavailable technologies. Evidence-based practice is related toproving that a service can be efficiently and effectively deliveredvia telecommunications technology. “Best-fit” approach is find-ing the best fit of technology to user, need and environment. Thepresentation is a discussion of that approach with exemplars.

P44THE SCI TELEHEALTH PROJECT: TELEMEDICINEIMPROVES ACCESS TO CARE FOR VETERANS WITHSPINAL CORD INJURYMichelle Hill, RN, MS, Leonard Goldschmidt, MD, PhD, GeorgeSullivan, MD, Linda Love, CNS, Susan Pejoro, RNP, InderPerkash, MD Veterans Affairs Palo Alto Health Care System, Palo Alto, CA

The Spinal Cord Injury (SCI) Service at the Veterans Affairs (VA)Palo Alto Health Care System is the expert center for care of Vet-erans with spinal cord injury or dysfunction residing in a largegeographic region, including the Hawaiian Islands and parts ofNevada. The expert specialty care is often far from the patientsserved. Distance and travel are particularly significant barriersto care for patients with spinal cord injury. We developed

telemedicine consultation to link the local VA medical centers inFresno, Honolulu, and Reno with the SCI Center in Palo Alto.Our goal was to provide timely, local access to specialty care.During weekly sessions, the local clinicians and the patients con-sult with the experts in Palo Alto utilizing videoconferencing,electronic patient records, digital radiology, and wound images.An examination takes place with the local clinicians as the“hands”, and the expert consultants offer “eyes and ears.” Clin-ician surveys indicate that teleconsultation resulted in earlieridentification and treatment of clinical conditions. In the first sixmonths, access to care was notably improved; 45% of the patientshad never before been seen by the SCI Center. Patient and clin-ician surveys indicate that they intend to continue to use tele-consultation.

P45DIAGNOSTIC UTILITY OF MPEG1 COMPRESSION OFECHOCARDIOGRAMSErnst Hoffstetter, MS, Daniel B. Rayburn, PhD, Marina Vernalis,DO, COL Ronald Poropatich, MDWalter Reed Army Medical Center, Telemedicine Directorate, Wash-ington, DC

Digitizing echocardiograms has become standard practice sincetheir resolution is greater than previously used VHS. The reso-lution of the digitized echocardiograms is comparable or en-hanced when compared to the quality of VHS resolution. Wetherefore assume no loss of diagnostic utility using digitized files.Transferring these large files from remote facilities to distantmedical centers is problematic. Data compression using MPEG1greatly reduces the file size but also reduces the image resolu-tion due to inherent destructive algorithms. The effect of this datacompression upon the diagnostic findings has not been previ-ously ascertained. We are currently studying to medical utilityof this system by comparing the diagnostic findings of the digi-tized signal with those of the VHS. Discrepancies of diagnosticsbetween the sources may be attributed to either the loss of res-olution or consultant variability. To determine where discrep-ancies occur, we are assessing the inter- and intra-consultant vari-ability of diagnostic findings from both data sources. The issues,status and data collected from this study will be presented.

P46TARGETING HOME CARE PATIENTS FOR TELE-HOMEHEALTH CARE SERVICESFaith P. Hopp, PhD,1 David M. Smith, MD,2 Peter Woodbridge,MD2

1Health Services Research and Development, VA Ann Arbor Health-care System, Ann Arbor, MI; 2Richard L. Roudebush VAMC, Indi-anapolis, IN

This presentation will describe a three-step process for identify-ing patients for participation in a tele-home health care program.The first step involves identifying patients at high risk for futurehealth resource use. Our inclusion criterion for patients in a VAhome care program included (a) one or more hospitalizations,two or more emergency room visits, or ten or more outpatientvisits in the prior six months, and (b) the use of home care ser-vices for at least one month. Approximately 45% (n � 170) of arecent cohort of VA home care patients met this criterion. Suchpersons were significantly more likely than other home care pa-tients to have a diagnosis of CHF, COPD or diabetes, and hadsignificantly more hospitalizations, ER visits, and outpatient vis-its in the six months following their first home care appointment.The second step involves the development of relevant exclusioncriteria, which include personal and environmental factors thatpreclude effective use of the technology, while the final step in-volves determining patient willingness to participate in tele-home health care. We will describe our experiences implement-

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ing these three steps, and the opportunities and challenges in tar-geting and recruiting patients for participation in tele-homehealth care services.

P47USING COLLABORATIVE PARTNERSHIPS TO DEVELOPONLINE ACCESS TO INFORMATION, PROVIDERS, ANDSERVICES FOR PEOPLE WITH DISABILITIESMichael Jones, PhDShepherd Center, Atlanta, GA

Advanced telecommunication and information technologieshave been proven useful, as a way to bridge the gap betweenthose with specialized care needs living in remote locations andthe sources of this specialty care. With the advent of high-speed,high-bandwidth telecommunications networks, telemedicine hasemerged as a significant component of the health care deliverysystem. The Internet already demonstrates the value of inter-connected information resources for business, government, edu-cation and medical applications. Even at the lowest bandwidthconnections, standard Internet protocols support extremely valu-able data communications. Advanced network capabilities, suchas those available with the Next Generation Internet (NGI), willprovide significantly greater access to home and community set-tings. This presentation describes a project that Shepherd Cen-ter and Georgia Institute of Technology, along with their corpo-rate partners Earthlink Inc, CyberCare, Inc and Siemens, Inc, areembarking on to link rehabilitation professionals with patientswho have sustained catastrophic brain and spinal cord injuries,their families and caregivers. The test-bed will emulate capabil-ities of the NGI including high-band width videoconferencing,remote monitoring, environmental control, and high-speed de-livery of interactive multimedia instructional materials.

P48RESEARCH STUDY ON HUMAN PATHOS WITH FLIGHTSIMULATOR 98Hiroshi Juzoji, MD,1 Isao Nakajima, MD, PhD,1 Yongguo Zhao,MD, PhD,1 Naoshi Kakitsuba, PhD,2 Masuhisa Ta3

1Tokai University Medical Research Institute, Isehara, Kanagawa,Japan; 2Ashikaga Institute of Technology, Ashikaga, Tochigi, Japan;3Tasada Works Inc., Takaoka, Toyama, Japan

This study attempted to quantify mental excitement in a VR en-vironment. Specifically, the study tracked the amount of waterevaporating from the palm over time as the subject maneuver-ing a flight simulator application, engaging in simulations of dif-ficult or dangerous flights. The consumer software applicationFight Simulator 98 was used as VR content on a PC running Win-dows 98. The flight begins at Tokyo Haneda Airport, where ajumbo jet takes off toward the south, rising in altitude. The sub-ject is free to select from several stimulating or dangerous flightsin advance, and to maneuver the plane as its pilot. This thrillingflight is not entirely realistic, although the plane takes off andlands in a specified airport with a real-world counterpart. Thevolume of water measured from the skin of all five subjects in-creased synchronously with the thrilling flight, though withsome individual variations in volume. These phenomena wereconsidered to represent episodes of mental sweating. Thrillingflights in a flight simulator; fear of crashing, neural arousal (rapidresponses of visual and motor fields), excitation of hypothala-mus, and increased blood flow of capillary arteries of the skin,increased volume of water from the skin. Current game systemsare unable to sense the player’s excitement. It has been foundthat interactive VR systems or game systems with programs ca-pable of detecting player arousal have many potential applica-tions, especially in the case of telemedicine.

P49ALASKA FEDERAL HEALTH CARE ACCESS NETWORKWanda Asta KellerAlaska Native Tribal Health Consortium, Anchorage, AK

The Alaska Federal Health Care Access Network (AFHCAN) isa federal telehealth initiative of the Alaska Federal Health CarePartnership to develop a statewide telecommunications network.The project mission is to improve access to health care for fed-eral beneficiaries in Alaska through sustainable telehealth sys-tems.

The AFHCAN project has 37 member organizations includ-ing IHS/Tribal entities, the Veterans Administration, Depart-ment of Defense, US Coast Guard, and the Alaska Departmentof Public Health Nursing.

The AFHCAN project is in the process of developing astatewide telecommunications network to link health careproviders at 235 sites including rural clinics, regional hospitals,and medical centers to referring health care providers.

P50TELEMEDICINE TECHNOLOGY IN THEINTERNATIONAL HEALTHCARE ARENA-BROADBAND APPLICATIONS USING IP ANDPOTSThomas A. Key, BS, CCNA,1 Raul C. Ribeiro, MD,1 Galen Briggs,PhD,1 Rich House,1 Dan Huss,1 Norman Costa,2 Franscisco Pe-drosa, MD,2 Bassem I. Razzouk, MD1

1St. Jude Children’s Research Hospital, Memphis, TN; 2InstitutoMaterno Infantil de Pernambuco (IMIP), Recife, Brazil

St. Jude Children’s Research Hospital Telemedicine Program cur-rently employs a multi-mode, multi-system, and multi-networkapproach to Telemedicine technology. We have established anInternational network, using ISDN as the primary protocol. We,also, use H.323 for broadband applications in an IP format toprovide Telemedicine videoconferencing capability, to transporthigh resolution, DICOM compliant radiology and pathology im-ages for diagnostic purposes, and to access patient records withassociated diagnostic images, and multimedia files. To accom-plish this, we have a Cisco/RAD 3520 Gatekeeper/Gateway be-hind a Madge M200 hub. Another element that enhances the Dis-tance Education component of the program is the Cisco 3416videostreaming system. For multiple domestic and internationalsite events, we use the ACCORD Bridge that allows simultane-ous 128 Kbs, 768 Kbs, H.323, and audio connections. The back-bone for our current network is two ISDN-PRI’s, terminating intoa DDM2000 over a SONET/SMARTPATH link. Web enabledTelemedicine applications that allow transmission of DICOMcompliant radiology and pathology images over POTS lines are,also, employed. For proctored telesurgery events, we use a SonyDXC-390 3 chip camera system at 768 Kbs in H.323 format. Weuse this technology for medical consultations, medical confer-ences, proctored telesurgery, and distance learning applications.

P51SUPER HIGH DEFINITION WITH SCREEN SPLIT WITHMULTI ENDOSCOPIC IMAGESNorio Kimura, MD, Hiroshi Juzoji, MD, Yongguo Zhao, MD,PhD, Isao Nakajima, MD, PhD, Takeshi Miwa, MDTokai University, Isehara, Kanagawa, Japan

We have conducted tests utilizing super high-definition CRTs(hereafter, referred to as a “super high-definition image system,”or “SHD”: 2048 � 2048 pixels, 24-bit RGB gradation, non-inter-lace system) for autonomous and distributed medical imagedatabase systems. The system is capable of providing 6 times theimage definition of a hi-vision television (HDTV). The aim in de-signing and testing the system is to enable gigabit network con-

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nectivity while displaying images on a DOS-V machine. This pa-per discusses how we can use SHD CRT for clinical image di-agnosis, especially screen splitting with multi-endoscopic im-ages.

High-definition still images ( SHDs ) such as full color endo-scopic images with screen split display are needed to recognizegastro-intestinal conditions of the patient, especially when thepatient suffers from some diseases. Additionally, the need to re-fer to a former patient’s image, or images of similar cases, mayarise for reference purposes. For such cases, we require screensplit display with high resolution.

A standard SHD file size of amounts to approximately 12 MB(uncompressed) or 4 MB (with lossless compression) per file. Toensure accurate diagnoses, we should avoid using compressionmethods that are prone to data degradation.

In over 50 clinical cases displayed on SHD its clinical useful-ness has been demonstrated as satisfactory.

P52TECHNOLOGY AND CARE COORDINATION:EFFECTIVE TEAMWORK FOR MANAGING CHRONICILLNESS IN GERIATRIC VETERANSRita Kobb, MS, MN, ARNP, CS, CWS, Robert Lodge, MSWNorth Florida/South Georgia Veterans Health System, Lake City, FL

The Rural Home Care Project in Lake City, Florida, is one of eightclinical demonstration projects in an expansive new technologyinitiative implemented by the Department of Veterans Affairs,Sunshine Network in Florida and Puerto Rico. The Rural HomeCare project has two care coordinators, a nurse practitioner andsocial workers that are collaborating with primary care providersto target high-risk veterans age 55 and older with diabetes, hy-pertension, heart failure, and obstructive lung disease. The pro-ject uses the Lifeview (telemedicine system and an in-home mes-saging device called the Health Buddy) to monitor projectpatients in an effort to reduce hospitalizations and ER visits, andto improve clinical outcomes and patient satisfaction. The eval-uation methodology includes interviews with questionnaires,and statistical analysis with an Intranet database tool. Prelimi-nary results show that the use of this technology correlates withincreased access to services, reduced health crises, and increasedpatient satisfaction.

P53ACCESS TO TELECOM SERVICES AND ROUTINEUSAGE OF TELEHEALTH APPLICATIONS: A EUROPEANSURVEYLutz Kubitschke, MA,1 Kevin Cullen, MA,2 Veli N. Stroetmann,MD, PhD,1 Karl A. Stroetmann, PhD, MBA1

1Empirica GmbH, Bonn, Germany; 2Work Research Centre Ltd.,Dublin, Ireland

In a European Union wide study to realistically assess the rele-vance of telemedicine applications in routine service provision,data on national policies and trends as well as on communica-tions between three major players—hospitals, GPs and citizens—and on health telematics applications were collected. Themethodological approach was based on an analytical concept ofthe players’ communications relationships and on health servicesintegration. Besides information on European health systemstructures and telehealth policy trends, data on access equip-ment, access to advanced networks (ISDN, leased lines) and ad-vanced services (Internet, dedicated health nets) for 15 countriesis presented. Experimental usage for 5 generic telemedicine ap-plication types based on surveys and country reports was de-termined. An analysis of 4 major facilitating and constrainingfactors—technology, health system structures, medicolegal andefficiency/reimbursement aspects—synthesizes this experienceand allows to derive a realistic picture of presently very limited

routine as well as experimental application of telemedicine. Tele-com access for all citizens and health policy implications are out-lined.

P54RECOMMENDED PRACTICES FOR PROTECTINGPRIVACY IN TELEHEALTHJoanne Kumekawa, MBADepartment of Health and Human Services, Rockville, MD

“The Role of the Office for the Advancement of Telehealth in theDevelopment of Policy for Patient Privacy in Telehealth,”

This presentation will provide a policy level perspective oftelehealth, focusing on emerging policy and legislation that willadvance the application of telehealth. Since one of the significantbarriers to widespread application of telehealth is concern aboutthe security and privacy of patient information, these recom-mended practices will be to serve as a starting point for assess-ing new legislation’s potential impact on telehealth practices anddeveloping meaningful guidance and policy.

P55THE PEARLS AND PITFALLS IN ESTABLISHING ADIABETIC RETINOPATHY SURVEILLANCE PROGRAMUSING TELEMEDICINEMary G. Lawrence, MD, MPH,1,2 Gary S. Michalec, BS, CRA,COA,1 Sandra K. Schmunk, BS, MA, HHSA1

1VA Upper Midwest Network, Minneapolis, MN; 2University of Min-nesota, Department of Ophthalmology, Minneapolis, MN

The purpose of this project was to establish an innovative dia-betic retinopathy surveillance program in a large Veterans HealthAffairs (VHA) Network. The technical, scientific and adminis-trative issues that were addressed will be presented.

Treatment for diabetic retinopathy (DR) is optimal if givenearly in the course of the disease, so annual retinal examinationsare the recommended standard of care in the USA. Compliancewith annual retinal exams, however, has been reported to be be-tween 18%-65%. The Upper Midwest Network of the VHA ex-tends across approximately 700 miles of sparsely populated area.At one remote site in the network, only about 48% of diabeticsreceived an annual eye evaluation.

A pilot program was established using telemedicine technol-ogy to provide retinal exams to the diabetic patient populationin one remote site within the network. Digital Retinal imageswere taken by staff at the patient’s primary diabetic care site. Thedigital images were transmitted electronically from the remotesite to the reading center, where ophthalmologists skilled in reti-nal evaluations looked for diabetic retinopathy. Implementationof this project required extensive planning to include technical,organizational, and personnel issues.

We demonstrated an increased compliance rate with annualretinal examinations standards for the remote site. Other out-comes, such as technical settings and utility analysis will be pre-sented. In conclusion; telemedicine technology provides a viablealternative to “face to face” examinations for the presence ofretinopathy in the diabetic population. Organization and opera-tional issues need to be considered in addition to questions re-garding costs and technology.

P56OPERATIONAL CHALLENGES AND OUTCOMES OFSTORE-AND-FORWARD TELEMEDICINE EVALUATIONOF DIABETIC RETINOPATHY IN A PRISON HEALTHCARE SYSTEMHelen K. Li, MD,1 Minh Dang, MS,1,2 Sami Uwaydat, MD,1 JohnHorna BS,1 Douglas J. Appel, OD,3 John S. Pulvino PA,3 Owen J.

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Murray, DO,3 Larry Johnson, PhD,3 Grace C. Chao, MD,3 LeonM. Clements,3 Ben G. Raimer, MD3,4

1Department of Ophthalmology & Visual Sciences, University of TexasMedical Branch, Galveston, TX; 2Department of Health Informatics,University of Texas Health Science Center, Houston, TX; 3CorrectionalManaged Care, University of Texas Medical Branch, Galveston, TX;4Community Outreach, University of Texas Medical Branch, Galve-ston, TX

Store-and-forward telemedicine evaluation of diabetic retinopa-thy is seen by many as an ideal application for remote eye caredelivery in a variety of patient populations. However, store-and-forward telemedicine presents many implementation challenges.Additionally, remote delivery of health care in a correctional caresetting includes unique considerations compared to telemedicinein general populations.

Store-and-forward teleophthalmology was used to evaluatediabetic retinopathy in a prison population. This study analyzesthe results of teleophthalmology at a remote regional medical fa-cility and the University of Texas Medical Branch tertiary carecenter. Analysis of teleophthalmology experience for approxi-mately 200 diabetic patients includes:

Data management, including storage, file compression, recordretention duration and transmission factors related to computertext and imagery data; Operator training requirements for dataacquisition; Review of factors related to diabetic patients whocould not be evaluated by store-and-forward telemedicine; De-lineation of special considerations and issues related to imple-menting a telemedicine system in prison setting.

P57INCREASING ACCESSIBILITY OF BREAST CLINICALTRIAL INFORMATIONAna Maria Lopez, MD, MPH, FACP, Sarah Frances Kurker,MSW, Michael TalleyUniversity of Arizona, Arizona Cancer Center, Tucson, AZ

Objectives: Clinical trials (CT) represent an important but under-utilized treatment option in the management of women withbreast cancer. The goal of this intervention was to develop, im-plement and evaluate a demonstration project to increase accessto breast cancer CT information via telemedicine.

Methods: The Arizona Telemedicine Program (ATP) providesteleconsultations to rural communities in the state of Arizona.The ATP sites were targeted to receive the CT information. Po-tential users were introduced to the web-based CT informationsite via press releases, newsletters, personal letters and telecon-ferences with on-line demonstrations. Access to the web site wasnot limited to medical personnel; therefore, technical languagewas not employed. Questions were encouraged via an interac-tive format. Once referred to a CT, screening and evaluationwould take place via teleconferencing.

Results: After 10 months of operation, the web-site has re-ceived 312 hits. Thirteen screening questions have been received.Statement of Impact: Access to the Internet provides unprece-dented access to information. This intervention increasedprovider and patient knowledge about CT and state of the arttherapies for breast cancer.

P58TUMOR BOARD PRESENTATIONS VIA TELEMEDICINEAna Maria Lopez, MD, MPH, FACP,1,2 Katherine Scott, MD,2 JayFleishman, MD,3 Sydney Lazarus, BS, BA,2 Herbert Schwaeger,PhD,2 Ronald Weinstein, MD2

1Arizona Cancer Center, Tucson, AZ; 2The University of Arizona, Tuc-son, AZ; 3Verde Valley Medical Center

In 1999, the Arizona Telemedicine Program (ATP) initiated a Tu-mor Board with a community in rural Arizona. Real-time inter-

active videoconferencing was employed to review oncologycases on a monthly basis. Approximately 2 cases were reviewedper session. Participants included oncologists, surgeons, radiol-ogists, primary care physicians and pathologists. Approximately,12–15 physicians were present at each session. In addition, to thetransmission of clinical information, histology and radiology im-ages were transmitted. Telecommunication was bi-directional.Cases reviewed included a broad spectrum of cancer cases in-cluding breast (2), bladder (2), lung (2), brain (1), thyroid (1),bone (1), tongue (1), uterine (1), pancreatic (1), endometrial (1),testicular (1), esophageal (1), and undifferentiated carcinoma (1).Reasons for the case presentations included diagnostic pathol-ogy review or clinical management concern. Over 80% of par-ticipants present at the rural sites agreed that new knowledgewas gained, that the educational objectives were met, and thatthe experience was intellectually stimulating. Tumor Board pre-sentations are feasible, well accepted and provide an example ofsuccessful multidisciplinary teleconferencing available to facili-tate patient care that would otherwise be difficult to coordinate.

P59DELIVERY OF PAIN MANAGEMENT CONSULTATIONSVIA TELEMEDICINEAna Maria Lopez, MD, MPH, FACP,1,2 Sydney Lazarus, BS, BA,2

Bennet Davis, MD,2 Nancy Cross, MD,2 Ronald Weinstein, MD2

1Arizona Cancer Center, Tucson, AZ; 2The University of Arizona, Tuc-son, AZ

The Arizona Telemedicine Program (ATP) has provided patientconsultations on pain management to rural communities in thestate of Arizona. A chart review of nineteen teleconsultations inthe area of pain medicine demonstrated that all consultations uti-lized real-time technology. Three required follow-up teleconsul-tations. Demographics: age 29–73 years, average of 45.1 years;men (7), women (12); White, non-Hispanic (7), Hispanic (4), un-known (8). The pain diagnoses were low back pain (8), fi-bromyalgia (2), abdominal pain (2), constant headache with lowback pain (1), rheumatoid arthritis with low back pain (1), radic-ular pain with low back pain (1), hip pain with headache (1),shoulder pain (1), scoliosis (1), and restless leg syndrome (1). Themajority of patients (11) received recommendations that allowedfor local management. These recommendations included med-ication adjustments and/or physical therapy or further diagnos-tic evaluations. Eight required in-person care for further evalu-ation and specialized pain therapy. Satisfaction was uniformlyhigh with the real-time technology and ease of communicationwith the teleconsultant. Based on these findings, it appears thatpain care consultations via telemedicine result largely in allow-ing patients to continue care locally. Further study is necessaryto delineate the role of telemedicine its efficacy and cost-effec-tiveness in patients with pain.

P60THE USE OF TELEMEDICINE IN THE CARE OF CANCERPATIENTSAna Maria Lopez, MD, MPH, FACP,1,2 Sydney Lazarus, BS, BA,2

Ronald Weinstein, MD2

1Arizona Cancer Center, Tucson, AZ; 2The University of Arizona, Tuc-son, AZ

The Arizona Telemedicine Program (ATP) provides telemedicineconsultations to rural communities in the state of Arizona. Achart review revealed 13 adult Medical Oncology teleconsults:real-time (1), store-forward (12). Demographics: age 37–78, av-erage 61 years; men (4), women (9); White, non-Hispanic (7), His-panic (1), Native American (5). Diagnoses: cancer of the breast(2), colon (2), rectum (2), duodenum (2), esophagus (1), kidney(1), diffuse large cell lymphoma (1), sarcoma (1) and cancer ofunknown primary (1). Four were new cancer diagnoses. One pa-

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tient underwent an initial teleconsult for a mass, a teleradiologyconsult for the recommended CT scan, a telepathology consultfor the biopsy and a telesurgical-oncology consult once the di-agnosis was made. Eight were second opinions for difficult clin-ical presentations. One was a follow-up to an Arizona CancerCenter consultation. Four required management at a tertiary carecenter. Nine received detailed clinical recommendations that al-lowed care to be provided locally. Patients were uniformly sat-isfied with the clinical outcome and agreed that telemedicine in-creased accessibility of clinical care. Teleconsultants (93%)expressed a high level of satisfaction with the telemedicine tech-nology and confidence with their telemedicine diagnosis. Basedon these findings, it appears that oncology care consultations arefeasible via telemedicine.

P61DYNAMIC COTS COMPONENT CONFIGURATION FORINTERNATIONAL TELEMEDICINE SYSTEMSINTEGRATIONAllen A. Izadpanah,1 David C. Kushner, MD, FACR,2 KennethLucas1

1Visual Telecommunications Network Inc., McLean, VA; 2Chairman,Diagnostic Imaging and Radiology, Children’s National Medical Cen-ter, Washington, DC

Emerging information and communications technologies havemade it possible to enable a physician’s clinic office to becometruly virtual. Physicians in the future will be have a digital of-fice at their finger tips wherever they may be, inclusive of med-ical records, high resolution images, full motion video, and wire-less communications that provide access to on-line medicalknowledge bases and clinical data repositories, all enabled on apocket-sized personal digital assistant (PDA). The major obsta-cle to this vision has been the inability to easily and dynamicallyintegrate legacy hospital informatics systems with the variousproprietary telemedicine software and hardware tools nowflooding the market. Our MedVizerTM telemedicine open sys-tems software enables a physician to quickly construct a com-plete digital clinic using virtually any telemedicine system com-ponents available in the market place. Last year at the ATA weintroduced the same technology in both Windows CE and Win-dows NT for pocket PC PDAs. Here we discuss our wirelesstelemedicine interoperability research being carried out with theUS Army, the University of Minnesota, and military and indus-trial partners in Norway. Our research is aimed at providingthese collaborators with the capability to quickly and dynami-cally configure COTS telemedicine components with both mili-tary and civilian informatics systems to enable the same full ser-vice digital office we now provide for use in the fixed clinic orhospital for the physician on the move.

P62OPERATIONAL CONSIDERATIONS WHEN STARTING ATELE-HOME CARE PROJECT: LEGAL ASPECTSSusan G. Slater, RN, BSN,1 Holly Russo, MS, BS,2 Robert Mac-Donnell, Esq.11Telemedicine Solutions in Healthcare-Pittsburgh, PA Regional Office,Corporate, Atlanta, GA; 2Tele-Health Consultant, Juno Beach, FL

Initiating a Telemedicine project within a home care setting takesmany hours of research and planning. There are many details,which must be thought through, in order to have a telemedicineprogram run smoothly. Telemedicine is a great tool to augmentthe care traditionally provided by the home care agency. Thestaff will find that the patients are very receptive to this tool, andwill love the flexibility telemedicine offers the staff to managetheir care. All members of the home care agency team; from thenon-clinical support staff to the clinical staff and administrators,need to work together to make this type of project work. It is

very important to have a telemedicine philosophy within the or-ganization, to get all of the staff to embrace the project. The pro-gram implementation issues that will be discussed are: equip-ment selection, tracking, and maintenance; staff training, patienttraining, peripheral device use, documentation, outcome mea-surements, and coordination of care using a (TCM) telemedicinecase manager.

P63TELEPHONE TRIUMPH: USING A NURSE-LED CALLCENTER TO IMPROVE THE COORDINATION OFMEDICAL CAREJohn Ross Maclean, MD, MBA, Brian Armour, PhD, Robert Cook,RPh, Jeff Etchason, MD, Adrianne K. Holmes, Jennifer L. Waller,PhD, Ellen Clements, RNMedical College of Georgia, Augusta, GA

Objectives: To determine the effectiveness of a nurse-led call cen-ter in (a) improving access to healthcare services and (b) reduc-ing medical center costs by improving the coordination of care.

Methods: The evaluation used administrative data from a ret-rospective study of patients at the Augusta VA medical centerfacility between April and September 1999.

Results1. Access

A survey of a random sample of callers (n � 63) revealed thatthe call center increased veteran access to pharmacy services andthat most callers were satisfied.

The Augusta VAMC primary care clinic average no-show ratefor appointments scheduled through conventional methods was21% (3,433/16,607) compared to an average no-show rate of 5.5%for appointments scheduled by Call Center nurses (24/436).2. Cost of service provision

Given the average variable cost per no-show ($65.13), the po-tential cost-savings that could be realized if all primary care clinicvisits were coordinated through the Call Center is estimated tobe $328,134 if aggregated to fiscal year 1999.

Conclusions: This study provides evidence that the imple-mentation of a call center increases the coordination of medicalcare and reduces no-show rates at VA medical center primarycare clinics. This reduction in no-show rates could potentiallysave Network-7 $328,134 per annum.

P64TRAINING FOR INTERNATIONAL TELEMEDICINELori Maiolo, David C. Balch, MATelemedicine Center, East Carolina University, Greenville, NC

Advances in distributed medical care require highly trainedmedical, emergency, civil, and defense personnel. Twenty-firstcentury disasters and threats require Americans be ready to re-spond both at home and abroad. Distributed Medical Intelligence(DMI) is a health care model developed at East Carolina Uni-versity (ECU) to focus on the use of technology to improve ac-cessibility and quality of care in the areas of greatest need. DMIwill achieve its full potential when well-trained first respondersand well-trained physician consultants can provide on-demandcare around the globe. The Telemedicine Center at ECU has de-veloped International training programs on both the technologyand organizational aspects of telemedicine in humanitarian re-sponse. The curriculum emphasizes the need to train personnelin the use of telemedicine equipment and protocols and to de-velop practical models for delivery of care any where in theworld. New components of the International training programinclude the use of simulations, case studies, and hands-on expe-riences.

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This presentation will provide an overview of InternationalTelemedicine Training program and the importance of trainingfor successful applications in emerging international models.

P65ACUTE CARE PROVIDED VIA HOMETELECAREFrances S. Mair, MBChB,1 Robert Angus, MBChB,2 Mark Wilkin-son, MBChB,2 Sandra Bonnar, RN,3Richard Wootton, PhD4

1University of Liverpool, Liverpool, England; 2Aintree University Hos-pitals NHS Trust, Liverpool, England; 3North Mersey CommunityTrust, Liverpool, England; 4Centre for Online Health, Australia

This study examines the feasibility of using home telecare tech-nologies to provide a safe alternative to admission for patientswith mild to moderate exacerbations of chronic obstructive pul-monary disease (COPD). In this study a team of specialist nurses,an Acute Chest Triage Rapid Intervention Team (ACTRITE), pro-vide home care (via an analogue video telephone) for patientsthat would otherwise be accepted for hospital admission withexacerbations of COPD. This project represents the first trialaimed at examining the utility of providing home telecare tothose experiencing an acute exacerbation of their chronic illness,who would otherwise have merited acute hospital admission.COPD is a disease that is a major contributor to rising rates ofemergency medical admissions. Thus this project examines theuse of new technology to address an issue of immense economicsignificance and of great practical importance to patients. Thusfar 20 patients have participated in the project. Preliminary re-sults have demonstrated the feasibility of using home telecare inthis context. The study findings particularly focusing on healthcare providers’ views and patient satisfaction and will be pre-sented.

P66DEVELOPMENT AND DEPLOYMENT OF A WEB-BASEDASTHMA TELEMEDICINE CONSULT SERVICE TO THEWESTERN PACIFICFrancis J. Malone, MD,1 Mark D. Ching, BS,1 Morgan S. Man-deville, MD,2 Karen L. Fitzgerald, RN, CPNP, MS,3Sharon P.McKiernan, MD,4 Scott T. Maurer, DO,5 Debora S. Chan,FAHSP6, Scott J. Sheets, DO,6 Charles W. Callahan, DO6

1Pacific e-Health Innovation Center, Tripler Army Medical Center,Honolulu, HI; 2United States Naval Hospital, Guam; 3374th MedicalGroup, Yokota Air Base, Japan; 4121 General Hospital, Seoul, Korea;5United States Naval Hospital, Okinawa; 6Department of Pediatrics,Tripler Army Medical Center, Honolulu, HI

Military providers in Okinawa, Japan, Korea, and Guam are par-ticipating in a Web-based consultation study of children withasthma. Consults are submitted using Internet “store and for-ward” technology to the pediatric pulmonologist at Tripler ArmyMedical Center in Hawaii. The consult includes a history andphysical, a digital chest radiograph (optional), digital spirome-try, a video clip of the patient’s MDI technique, and a quality oflife questionnaire. Fifteen patients (ages 6–18) with persistentasthma will be enrolled from each site and followed on a clini-cal pathway for one year. Patient’s MDI scores, utilization of re-sources, acceptance of telemedicine consultation, and quality oflife will be measured. Practitioner acceptance of the technologywill also be assessed.

RESULTS: To date, 4 male and 1 female patient, aged 10.96� 2.99 years (mean age � SD) have been enrolled. Three hadmoderate and two had severe asthma. All children had insuffi-cient MDI scores ( � 70%) at time of consult. Average MDI tech-nique score was 42% � 20.37%, range 12.5–66.7%. Other datapoints are pending.

CONCLUSION: This study will demonstrate the utility andeffectiveness of telemedicine consultation to assist providers in

caring for children with asthma. Funding provided by a grantfrom Pacific e-Health Innovation Center.

P67TELEDERMATOLOGY THROUGH PROTOTYPEINDEPENDENT VERIFICATION AND VALIDATION(IV&V) SUPPORTRonald Marchessault, Jr., MA, MBA Candidate,1 Cheryl A. Mer-ritt, MA2

1Information Systems Support, Inc., Bethesda, MD; 2SRA Interna-tional, Inc., Fairfax, VA

The Walter Reed Army Medical Center has developed a work-ing Teledermatology prototype using Commercial-Off-The-Shelfand government developed applications which supports Der-matology patient encounters, patient consultations, and physi-cian referrals. The prototype has undergone fielding to RegionalMedical Centers in Europe and CONUS where user feedback hasbeen positive. The deficiencies of the current practices are docu-mented in the Operational Requirements Document for the Med-ical Equipment Set, Telemedicine dated 12 FEB 98. The Teleder-matology System uses digital cameras and web technology toprovide a consult service, using store-and-forward methodology.It is being proposed as an Acquisition Category IV system.

To build on the success of the Teledermatology application itis necessary to move the project from a research and develop-ment effort into a formal acquisition program. This begins witha two-step process:

1) Determine the telemedicine programmatic and technical re-quirements;

2) Assess the prototype application’s compliance with currentUS Army and DOD technical standards and software develop-ment practices.

P68INTERNET-BASED TELEDERMATOLOGY PEER REVIEWQUALITY IMPROVEMENT ENHANCEMENT OFTELEDERMATOLOGY SYSTEMMary K. Mather, MD,1 Thomas R. Bigott, BS,2 Zhengyi Sun, MS,2

COL Ronald K. Poropatich, MD,2 Paul Benson, MD1

1Dermatology Service, Walter Reed Army Medical Center (WRAMC),Washington, DC; 2Telemedicine Directorate WRAMC

Background: The Walter Reed Army Medical Center (WRAMC)has been using a store-and-forward Web-based telemedicine sys-tem for Dermatology consultation since May 1998 and has over1,500 consultations to date. No outcome assessment has beendone and no outcomes measures have been instituted to trackquality of care.

Methods: WRAMC Dermatology Service is currently trackingall TeleDermatology consultations received and answered byWRAMC Dermatology Providers. The current study will con-tinue for a 6-month period. The current system tracks patient-outcomes using telephone contact at 2 days and 30 days follow-ing their TeleDermatology consultation.

Results: The following outcomes measures are currently be-ing recorded: time from consultation to patient contact for fol-low-up, time between initial telemedicine consultation and pa-tient visit to Dermatologist (when recommended), number ofpatients who fail to comply with the initial electronic recom-mendations for treatment or biopsy, the number of provider vis-its required to resolve the patient’s chief complaint, and the per-centage of patients who are successfully managed through theelectronic consultation alone.

Conclusion: This study should provide a meaningful assess-ment of the outcomes of the current system. Data suggestingmodifications to the current system will be studied in order toimprove patient outcomes and ultimately patient care.

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P69TYPES OF TELECONSULTATIONS AND THEIRFACILITATIONJerrold H. May, PhD,1 Luis G. Vargas, PhD,1 COL Ronald K.Poropatich, MD,2,3 William G. Jacobs,1 Gary R. Gilbert,1,2 LindaR. Youngblood Sales, BS,3Mitra A. Rocca, MSc1,2

1AIM Laboratory, University of Pittsburgh, Pittsburgh, PA; 2UnitedStates Army Medical Research & Materiel Command (USAMRMC),Telemedicine & Advanced Technology Research Center (TATRC), Ft.Detrick, MD; 3Walter Reed Army Medical Center, Washington, DC

The study analyzed the consultation records from a U.S. Armyteledental system as part of the design and construction of theConsult Broker part of the Global Grid Telemedicine System. Aspresented at ATA 2000, teledental consultations appeared to fallinto three categories: (1) patient referral; (2) information request,but the requester will continue to treat the patient; and (3) infor-mation request in which the requester will treat the patient if rou-tine but will refer if treatment is beyond his/her competence. Inextending the Consult Broker prototype to general medical prob-lems, we are studying data from the Ask-a-doc systems at WalterReed Army Medical Center. The Ask-a-doc data includes othercategories of consultations, such as administrative questions anddrug therapy questions. In systems such as Ask-a-doc, the personwho requests the consultation chooses a particular consultant spe-cialty, but sometimes a different specialty would have been a bet-ter choice and sometimes expertise from more than one specialtyis required to answer the question. We discuss the patterns wefound in Ask-a-doc, compare them with teledentistry, and pro-pose frameworks for the Consult Broker that could provide assis-tance for different types of teleconsultation systems.

P70WIRELESS TRANSMISSION OF TELEMEDICINEAPPLICATIONS TO THE PATIENT BEDSIDEJames Mayrose, PhD, David G. Ellis, MD, James O. WhitlockState University of New York at Buffalo, Buffalo, NY

Telemedicine is concerned with ways in which computers andtelecommunication can be combined to improve the quality ofhealth care by linking remote sites with centers of expertise. Wehave developed a system that allows us to not only deliver thistechnology to a remote site but to go one step further and deliverit to the bedside of any patient within that facility. We achieve thisthrough the use of wireless network technology.

Wireless networking refers to technology that enables two com-puters to communicate using standard network protocols, butwithout network cabling. The wireless network developed hereuses an access point that acts like a hub, which provides connec-tivity for the wireless computers to the wired LAN. LAN resourcesand Internet connectivity are then available to the wireless end-points. A mobile PC-based telemedicine system, which utilizes theH.323 standard for the transmission of real-time video, audio anddata over packet-based networks was developed. The high per-formance video and small footprint of this equipment allows thissystem to be easily integrated into any healthcare facility.

The system developed here allows small, remote healthcarefacilities to deliver the expertise of medical professionals at otherfacilities directly to the patients’ bedside.

P71PROMOTING TELEMEDICINE TO GOVERNMENTPOLICY MAKERSDon McBeath, BA; Shannon Kennedy, MBATexas Tech University Health Sciences Center, Lubbock, TX

While telemedicine has gained support in the medical field in re-cent years, general public support of this technology has lagged.

Increasing awareness is crucial since support by government andcommunity policy makers is vital to the growth of telemedicine.The Texas Tech University Health Sciences Center (TTUHSC)telemedicine program developed an informational direct-mailnewsletter, written to provide basic knowledge about the opera-tions and benefits of telemedicine. This quarterly Telemedicine Re-port targets policy makers in the TTUHSC service area who are ina position to support telemedicine at a funding and regulatory level.The audience includes mayors, county judges, school superinten-dents, and hospital administrators. The Texas Governor, Lt. Gov-ernor, members of the state legislature, the Commissioner of Health,members of the Texas congressional delegation, and various stateofficials in adjacent New Mexico are also sent a newsletter.

The newsletter is designed to be a generic informational pieceabout telemedicine, rather than a promotional piece for theTTUHSC telemedicine program (although Texas Tech is clearlyidentified as the source). Because telemedicine is an integral com-ponent of health care, the newsletter also features some generalhealth information.

This presentation will outline marketing strategies as well assample newsletter designs.

P72HIV CARE FOR INMATES: A COMPARISON OFTELEMEDICINE AND FACE-TO-FACE CLINICSDonnie McGrath, MD,1,3Kathy Lasch, PhD,2,3 Jennifer ChungLee, PhD2,3 Therfena Green, BA,1,3 James Stahl, MD,4 JosephBakan, MA,3 Joseph Cohen, MD1,3

1Lemuel Shattuck Hospital, Boston MA; 2The Health Institute, Clini-cal Care Research Division, New England Medical Center, Boston,MA; 3Tufts University School of Medicine, Boston, MA; 4Massachu-setts General Hospital-Harvard Medical School, Boston MA

Infectious disease care is a common application of telemedicinein the US. However data describing the nature or effectivenessof this application is limited. We compared HIV telemedicineclinics in 3 Massachusetts prisons with traditional onsite face-to-face clinics over a two-year period. This is part of the Massa-chusetts Telehealth Access Project (MASSTAP), a prospectivequasi-experimental study evaluating telemedicine cost-effective-ness and health outcomes amongst inmates who participate intelemedicine. Clinics are performed via interactive videoconfer-encing over ISDN lines (384kbs).

Methods: Clinical and technical data was prospectively col-lected about telemedicine clinics using a structured data collec-tion instrument. Patients and providers were interviewed to as-sess satisfaction and acceptance. Clinical data was prospectivelycollected about face-to-face clinics.

Results: We collected data on 50 telemedicine clinics and 15 on-site clinics. There were no significant differences in average con-sultation time, percentage of routine visits (no new symptoms/signs, no medication changes) or complicated visits (involved med-ication changes and/or involved new symptoms/signs). Patientand provider satisfaction rates were high with the telemedicineclinics.

Conclusion: HIV patient management using telemedicine issimilar to traditional care. In addition both patients andproviders express high levels of acceptance and satisfaction withtelemedicine clinics.

P73USE OF A VIDEOSTREAMING SERVER FOR THEDELIVERY OF CONTINUING EDUCATION OVER ATELEMEDICINE NETWORK TO RURAL HEALTHCAREPRACTITIONERSRichard A. McNeely, MA, John R. Hall, PhD, Cynthia A. Frank,MS, Richard A. Collins, BFA, Kenneth E. Umphrey, BFA, RonaldS. Weinstein, MD

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Arizona Telemedicine Program, Arizona Health Sciences Center, Uni-versity of Arizona, Tucson, AZ

Established in 1996, The Arizona Telemedicine Program is a mul-tidisciplinary clinical program of The University of ArizonaHealth Sciences Center. The program operates telemedicine clin-ics in 14 communities and is linked for distance learning to 31 af-filiated organizations at 38 sites. The programs broadband ATM-T1 network simultaneously delivers real time video, data, andInternet services to these sites. Continuing education via con-ventional interactive real time video began in 1999, in collabora-tion with the centers Division of Biomedical Communications,which provides video origination services from the centers pri-mary teaching facilities. To date, over 200 continuing educationsessions have been delivered to over 2,200 attendees. Sessions in-clude grand rounds in internal medicine, pediatrics, psychiatry,public health and surgery. A videostreaming server allows thisprogramming to be viewed over the Internet. Currently, all realtime distance learning sessions are simultaneously videostreamedand past sessions are available through the videoserver’s archives,along with digitized collections of presenters’ teaching slides. Theserver also provides curriculum-based presentations for reviewby students on rural rotations and at home in urban areas. Ouranalysis shows that videostreaming educational programmingcan be an important offering of a telemedicine program.

P74TECHNOLOGY ASPECTS OF ESTABLISHING APHOTOGRAPHIC TELEMEDICINE DIABETICRETINOPATHY EVALUATION PROGRAMMary Gilbert Lawrence, MD, MPH, Gary S. Michalec, BS, CRA,COA, Sandra K. Schmunk, BS, MA, HHSA.VA Upper Midwest Network, Minneapolis, MN

This presentation will discuss issues that need to be addressedwhen establishing a photographic diabetic retinopathy evalua-tion program utilizing telemedicine.

Diabetic retinopathy is the most frequent cause of new cases ofblindness among adults ages 20–74. Clinical trials have shown thatlaser photocoagulation can reduce the risk of severe visual loss, buteffectiveness of this treatment requires early detection. Unfortu-nately, well over half of the diabetic patients do not visit a quali-fied eye care provider as recommended. It has been proposed thatthis under served population can be evaluated in the primary caresetting utilizing digital retinal photographs. These images can thenbe transmitted to a centralized reading center where they will beevaluated for degree of retinopathy and need for referral. It ishoped that this evaluation will serve in lieu of an annual retinalexam that is performed by a qualified eye care provider.

In establishing such a program many technological obstaclesneed to be overcome. Selection of imaging equipment, image stor-age and transmission, and efficacy of new imaging technology inidentification of retinal pathology are a few of these items. Thispresentation will address these obstacles and the evolution of theMinneapolis VAMC diabetic retinopathy evaluation program.

P75MANAGING TERMINAL CANCER PATIENTS VIATELECONFERENCEGlenn M. Mills, MD,1 JoAnne Alley, MD,2 Victoria Ratts, RN,MS,1 Richard Mansour, MD,1 Ravindra Patil, MD,1 Benjamin Li,MD,1 Gary von Burton, MD,1 Federico Ampil, MD1

1Louisiana State University Health Sciences Center, Shreveport, LA; 2E.A. Conway Hospital, Monroe, LA

The aim of the study was to improve terminal cancer patientmanagement at an outlying facility, 100 miles east of our Uni-versity, through a consensus-based decision making process viaa Tumor Board teleconference.

Materials and Methods: Weekly multidisciplinary teleconfer-ences, explored options for patient management identifyingthose with end-stage disease. Attendees met in respective video-teleconference rooms. Surgeons, oncologists, internists, patholo-gists, radiation oncologists, nurses, clinical research associates,fellows, residents and medical students participated. The chiefoncological surgeon at the affiliate hospital and a University on-cologist moderated the teleconferences. Case descriptions faxedfrom the affiliate prior to the teleconference identified other con-sultants needed. Pathology and radiological images were trans-mitted for correlating diagnosis with stage. Each case discussedrendered decisions by a consensus-based approach.

Results: Over 3-1/2 years, (32%) of patients were determinedto have end-stage disease. Recommendations for palliative carewere proposed, such as radiation therapy for pain, enteral nu-tritional support, hospice services, etc.

Conclusions: Patients benefited from this teleconference ap-proach in decision making by reducing the time, discomfort andcost of traveling to the University. The teleconference forum re-sulted in more rapid implementation of terminal care, providingimproved patient management and providing an educationaltool for trainees regarding ethical decisions for end-stage diseasemanagement.

P76INTERACTIVE VIDEO CONFERENCE EDUCATION IN AFAMILY PRACTICE CENTEROrlando F. Mills, MD, MPH,1 Vicki Pendleton, RN,1 James F.Bates, PhD,2 Kathleen Lese, MA, MLIS,3Michael Tatarko, MD1

1Conemaugh Memoral Medical Center, Johnstown, PA; 2Center of Ex-cellence for Remote and Medically Underserved Areas, Loretto, PA;3Southcentral Area Health Education Center, Loretto, PA

Residencies are required to conduct weekly lectures for residents,often a time-intensive process. Two-way videoconference tech-nology may be a useful adjunct in Family Practice education byexpanding the possible lectures available for residents.

Methods: Live videoconferences were arranged between oursite and other sites. Participants at our site completed standardevaluation forms and rated the technical quality and perceivededucational value. We performed a quantitative and qualitativeanalysis of the evaluations.

Results: We conducted 30 videoconferences between our res-idency program and other sites and analyzed 382 evaluationforms. Overall the quality was good. Our worst conferences suf-fered from poor sound or video transmission. In our best con-ferences there was good sound and video, speakers gave clearhandouts in advance and showed slides that were not overlywordy or complicated.

Conclusions: Two-way videoconference education was a use-ful adjunct for our Family Practice Residency over the two yearperiod of operation. In the future there may be a role for thistechnology to help programs share their medical expertise withother programs without leaving their site.

P77STATEWIDE BEHAVIORAL HEALTH NETWORK INARIZONACatherine Romeo-Woff, MA, Susan Morely, MSW, Sara Gibson,MDNorthern Arizona Regional Behavioral Health Authority, Flagstaff, AZ

Northern Arizona Regional Behavioral Health Authority(NARBHA) was founded in 1967 and is under contract with theArizona Department of Health Services for providing behavioralhealth services to the northern region of the state. Since its in-ception, NARBHA placed a high priority on developing com-munity based behavioral health services with provisions to pro-vide services to adults, children, families, alcohol and drug

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clients, and the seriously mentally ill in outpatient, residential,and in-patient settings.

With a 62,000 square mile area, NARBHA faced numerousdifficulties in delivering care. In 1996, NARBHA began itsTelemedicine operation and has two video-conferencing sitesFlagstaff, two Phoenix sites, Show Low, St. John’s, Page, Prescott,Springerville, Holbrook, Kingman, Lake Havasu, Winslow, Bull-head City. NARBHA connected the network sites of CommunityPartnership of Southern Arizona, with six Tucson sites, Benson,Douglas, Nogales, Sierra Vista and the Pinal Gila BehavioralHealth Authority site in Apache Junction. NARBHA establisheda permanent network connection to the University of Arizona’sTelemedicine Program for continuing medical education andspecialty consultation. This year, the four RBHA, 43 site networkwill become centralized by adding The Excel sites from Yumaand LaPaz counties, forming the largest state-wide behavioralhealth network in the country.

P78TELEHEALTH IN THE ASIA PACIFIC (1999–2000)Isao Nakajima, MD, PhD,1 Hiroshi Juzoji, MD,1 Yongguo Zhao,MD, PhD,1 Norio Kimura, MD,2 Yuhwsuke Sawada, MD, PhD,2

Yoshihiro Takashima, MD, PhD3

1Tokai University Medical Research Institute, Japan; 2Tokai Univer-sity School of Medicine, Japan; 3International Medical Center of Japan,Japan

From the summer of 1999 to the spring of 2000, a study was fo-cused on the management and operational status of telehealth inthe Asia Pacific. The writers gathered materials upon returningto Japan to provide as detailed a report as possible on the cur-rent status and analysis of telemedicine in this region. There arenumerous medical support activities currently operating in theAsia Pacific region as follows;

1) Fiji School of Nursing: working in cooperation with the FijiMinistry of Health, the Fiji School of Nursing has been provid-ing monthly nursing education, under guidance from WHO’s Of-fice of the Representative for the South Pacific, since 1991. Of-fered continuously over this period, the weekly program centersaround three main sites: the

2) WPHNet (Western Pacific HealthNet) is a web-based med-ical consultation site managed and operated by the Pacific BasinMedical Association.

3) PACNET is also an Internet project, it is a more loosely-tied network that relies on e-mail running on autonomous dis-tributed systems supported by the SPC (Secretariat of the PacificCommunity), located in Noumea, New Caledonia.

4) Indonesia video telemedicine: With analog public circuitline, two-way video conferencing telemedicine are performed onclinical medicine.

5) TAMC (Tripler Army Medical Center) Telemedial opera-tion.

6) STAN (State of Hawaii Telehealth Access Network)

P79HEALTHY STEPS INTERVENTION FOR ADOLESCENTPARENTS OVER INTERACTIVE TELEVIDEODavid Cook, PhD, Eve-Lynn Nelson, MA, Pamela Shaw, MD,Gary C. Doolittle, MDCenter For TeleMedicine and TeleHealth, University of Kansas MedicalCenter (KUMC), Kansas City, KS

The Healthy Steps for Young Children Program is a national ini-tiative focused on enhancing the physical, emotional, and intel-lectual development of children from birth to age three. The lo-cal project links Healthy Steps Specialists with adolescent parentsat an urban high school using telemedicine. The presentation willaddress collaboration among the telemedicine department, themultiple granting agencies, the Healthy Steps specialists, and the

school system in implementation. The quantitative design com-pares adolescent parents who receive Healthy Steps care face-to-face with those who receive Healthy Steps care over ITV. In ad-dition to general demographic information, outcome measuresfor prenatal care include: attendance and knowledge of HealthySteps information presented in lecture and handouts; adherenceto prenatal visits and recommendations; and use of externalagencies. Outcome measures for postnatal care include: parentmeasures (completion of school; feelings of competency; etc.); ad-herence measures (immunizations; car safety; home safety; etc.);and infant developmental measures. Information concerning im-plementation and initial data will be presented.

P80TELEMEDICINE PROVIDER PERCEPTIONS OFDIAGNOSTIC AND TREATMENT EFFICACY IN APEDIATRIC POPULATIONEve-Lynn Nelson, MA, Pamela Shaw, MD, Gary C. Doolittle,MD, Georgina Peacock, MD, David Cook, PhDCenter For TeleMedicine and TeleHealth, University of Kansas MedicalCenter (KUMC), Kansas City, KS

Ten telemedicine providers completed a structured interviewconcerning reasons for telemedicine use and diagnostic and treat-ment efficacy. The median provider profile was a female pedia-trician in her mid thirties. Pediatricians identified a number ofbarriers to care and reasons for use of telemedicine in this urbanpopulation (lack of insurance, transportation difficulties, workconflicts, childcare barriers, language barriers, etc.) Providersemphasized the importance of experienced on-site nurses in thedevelopment of rapport with the family and in equipment use.The majority of providers (8 of 10) reported preference for face-to-face visits but view telemedicine as an acceptable alternative.On a Likert scale from 1 (very positive) to 7 (very negative), theaverage physician rating of comfort with equipment, reliabilityof equipment, audio quality, and video quality was between 2and 3. Diagnoses based on history were viewed as the best eval-uated over telemedicine. Technology (128 kb/s ISDN technol-ogy) enhanced some visuals, such as the ear TM is magnified onthe screen. Pediatricians expressed concerns around treatmentavailability (as with asthma breathing treatment) and concernsaround adherence (as with antibiotic pills versus injection foracute infections) using telemedicine. An ongoing study comparesthe perceptions of telemedicine providers with non-telemedicineproviders.

P81RESEARCH APPROACHES TO ESTABLISHINGTELEMEDICINE EFFICACY IN A BEHAVIORALPEDIATRICS SETTINGEve-Lynn Nelson, MA,1 Martha Barnard, PhD,1 Sharon Cain,MD,1 David Ermer, MD2

1University of Kansas Medical Center (KUMC), Kansas City, KS;2University of South Dakota Medical Center, Sioux Falls, SD

Research in traditional, face-to-face clinic settings consistentlysupports the efficacy of cognitive behavioral therapy (CBT) inthe treatment of childhood depression. The researchers adapteda CBT protocol for childhood depression in the ITV context.Their ongoing research compares an eight-week CBT interven-tion over 128 kb/s ISDN to face-to-face care at the medical cen-ter. The project is recruiting thirty families over 2 years. Aftermeeting the childhood depression criteria as assess by the Kid-die Schedule for Affective Disorders and Schizophrenia, fami-lies complete the Childhood Depression Inventory and the Be-havior Assessment System for Children. The preliminary datasuggest child improvement from pre- to post-assessment fromthe parent perspective and the child perspective at similar rates

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for both groups. The attendance and attrition rates did not sig-nificantly differ between the ITV and the face-to-face groups.The ITV equipment worked consistently across the visits butsome issues to consider include adequate lighting to see facialexpressions, ITV rooms that are wheelchair accessible, supervi-sion at distant sites, and privacy issues secondary to room con-trol at distant sites and to technology. Cognitive behavioral ther-apy appears well suited to the ITV context because itsstructured, goal-oriented sessions fit the strict scheduling de-mands of ITV line use.

P82TELEPSYCHIATRY IN A RURAL JAIL POPULATIONCharles Zaylor, MD,1 Eve-Lynn Nelson, MA,2 David Cook, PhD2

1Lansing Correctional Facility, Lansing, KS; 2University of KansasMedical Center (KUMC), Kansas City, KS

The psychiatrist conducted a telepsychiatry clinic with a ruraljail population over 20 months. The clinic followed a quadraticgrowth trend, moving from crisis intervention care (approxi-mately 10 inmates/month) to intervention with chronic disor-ders (approximately 70 inmates/month). The most common di-agnoses were affective disorders (44%) and adjustment reactions(22%). Substance dependence, abuse, or withdrawal was diag-nosed in over half the consults, again consistent with the highpercent of drug use in other correctional settings. The studyasked inmates and the psychiatrist to complete ratings of im-provement over time. The patient rating of improvement (Symp-tom Rating Checklist-90-Revised) and the provider rating of im-provement (Clinical Global Impression Scale Severity Index)correlated significantly, validating the clinical impression that in-mates respond the same to telemedicine services as face-to-faceservices.

P83TELEMEDICINE EVALUATION OF RESPIRATORYSYMPTOMS IN PATIENTS PRESENTING TO THEEMERGENCY ROOM: A COMPARISON STUDYMark A. Novas, MD,1 Robert L. Bratton, MD,1 Theodore Szy-manski, MD,1 Peter O’Brian, PhD,2 Patrick Healy, MBA1

1Mayo Clinic Jacksonville, FL; 2Mayo Clinic Rochester, MN

Objectives: To access the reliability of telemedicine examinationon patients presenting to the emergency room with respiratorysymptoms and to compare the efficacy, efficiency and cost-ef-fectiveness of telemedicine examination compared with the con-ventional examination.

Methods: 500 telemedicine visits will be conducted from theemergency room setting. Patients in no acute distress will beidentified in triage and directed to the telemedicine unit. Patientswill connect with the physician on-call and be evaluated viatelemedicine using the otoscope, electronic stethoscope, oxygensaturation monitor, thermometer, and peak flow meter. Thephysician linked via telemedicine will then record their assess-ment and plan. The patients will then be evaluated by the on-site physician. The diagnosis and treatment plans will then becompared.

Results: This is a study in-progress. Results are pending.Conclusions: (anticipated) Based on the observations and

methods used, a basis for the reliable use of telemedicine to eval-uate patients with respiratory symptoms was established. Com-pared with a formal visit to the emergency room, the cost of atypical telemedicine evaluation would be x, this compares withthe ER cost of providing care to the population studied of y. Allout-liers will be identified and discussed, i.e. those patients thatin the estimation of the EM physician ultimately required eval-uation and treatment in the ED. Additionally, a cost comparisonwill be carried out.

P84A NOVEL TREATMENT PARADIGM FOR FRAGILEPSYCHIATRIC OUTPATIENTS: COMBINING OFFICEBASED CARE AND TELEPSYCHIATRY—RX FORSUICIDE PREVENTION AND LOWER COSTSAnn Oberkirch, MDYale School of Medicine, New Haven, Connecticut, Woodbridge, CT

*No abstract available.

P85A CLINICALLY DRIVEN, TECHNICALLY BASEDCARDIAC TRIAGE SYSTEMKrisan Palmer, RN,1 Robert MacDonald, MD,1 Richard Scott,PhD,1 David Garnett2

1Atlantic Health Sciences Corporation, Saint John, New Brunswick,Canada; 2Aliant Telecom. Inc, Saint John, New Brunswick, Canada

The New Brunswick Heart Centre (NBHC) receives over 1200hospital-to-hospital transfers per year. Recognizing the value ofgetting the right patient to the right place at the right time to bestutilize scarce resources and to ensure a high quality of patientcare for this population, the NBHC initiated a single entry pointfor the referral process.

Prior to this successful research and development project, pa-tient data relayed was often inconsistent and unreliable. Refer-rals were received in any one of eleven different ways and as-sessed by one of as many cardiologists.

In conjunction with remote physicians, NBHC cardiologistsdeveloped a standardized triage assessment tool. Technologypartners automated the process and it was implemented in De-cember 1998 on a provincial basis. The process now has clinicalinformation entered, ECG’s scanned and patients automaticallyscored, reviewed and the priority for transfer assigned. To date,remote clinicians are satisfied with the increase in clinician ac-cessibility and information flow.

This objective, systematic approach to cardiac triage (c-triage)has proven its worth within the provincial healthcare system bymarkedly decreasing repeat laboratory testing, the need for in-ternal transfers, and inappropriate transfers. It has provided anavenue for interactive, real time, online consulting. This has en-hanced the medical management of patient’s prior to transfer.

Quality patient care, increased accessibility, acceptability andcost effectiveness have facilitated the use of c-triage on an inter-provincial basis.

P86HEALTH CARE PROMOTION OF THE CANCER PATIENTWITH TELEMEDICINEHemendra Pathak, MSc, MDAEDC Limited, Guwahati, Assam, India

The technically backward and geographically isolated North East-ern part of India is getting worldwide connectivity through VSATfrom block level Community Information Centre (CIC). Now theproblem of surface transport communication hindered by hills andforest will be partly solved through the CIC’s network.

Unfortunately, this part of India is full of cancer patients. Soif a coordinated telehealth effort connecting the medical profes-sional and telecommunication can be established then the healthservices can be provided to the rural residents including med-ically underserved and isolated area by the round-the-clock ac-cess to the medical care facility. By interlinking different health-care providers through a broadband infrastructure forconsultation between physicians and specialists, the long dis-tance travel of the rural patients can be eliminated.

Again with the help of this telemedicine network informationof cancer patient from remote location in respect of their type ofcancer, suffering duration, environmental condition including

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drinking and rainwater can be obtained. By application of scin-tillation counter, Gamma camera, study of radioactive emissioncan be made which in turn can be stopped by appropriate sci-entific methods that will help to remove the human health haz-ards particularly in India and to the world in general.

P87EFFICIENTLY MANAGING NONTRADITIONALADVANCED MEDICAL TECHNOLOGY R&D—THETATRC BUSINESS MODELJan M. Patterson, BA, Katherine Eltzroth, MHA, Conrad Clyburn,MAUnited States Army Medical Research & Materiel Command (US-AMRMC), Telemedicine & Advanced Technology Research Center(TATRC), Ft. Detrick, MD

Management of advanced medical technology research and de-velopment (R&D) programs and projects are a significant com-ponent of the Telemedicine and Advanced Technology ResearchCenter’s (TATRC) operational mission. These programs and pro-jects are administratively and technically complex, unique, andoften cut across (the TATRC’s) traditional organizational lines.Therefore, the TATRC has developed a detailed, complete pro-gram/project planning and control framework in order to suc-cessfully manage a program/project from inception to comple-tion.

The framework is characterized by five interrelated lifecyclephases: Inputs, Controls, Mechanisms, Execution, and Outputs. Inshort, science is sought (e.g. through announcement vehicles) andreceived (e.g. proposals) in the “Inputs” phase; subjected to rigor-ous functional and scientific review in the “Control” phase; if ap-proved, matched with the optimal funding source and/or programin the “Mechanisms” phase; monitored/managed through tech-nology review in the “Execution” phase; and finally transformedinto an end or transferable product in the “Outputs” phase.

P88TELEMEDICINE GUIDELINES: MANAGING A DYNAMICPROCESSLorraine Pellegrino, RN, MHA, Thomas S. Nesbitt, MD, MPHUniversity of California, Davis Health System, Sacramento, CA

Patients are frequently and inappropriately referred for special-ist care by their primary care physicians. To reduce the poten-tial for this occurring in telemedicine clinics, guidelines were pre-pared to indicate which clinical conditions are best suited fortelemedicine. Both primary care physicians in the communityand specialists within the UC Davis Health System were con-sulted to determine the amount of time needed for initial andfollow-up evaluation, training required to operate medical pe-ripheral devices (ie, examination camera, nasopharyngoscope),and clinical information needed by the specialist to complete thepatient assessment. The specialists at the UC Davis Health Sys-tem provide constant monitoring of appropriate conditions fortelemedicine based on thorough medical record review of pa-tients referred for telemedicine. When patterns of inappropriatecare arise, the guidelines are modified to reflect standards of ‘bestpractice’. Specialists also report to a clinical nurse manager whoserves the important function of liaison between specialty andprimary care; in this role, the nurse tracks improvements neededin examination skills, technical problems with the equipment,and the availability of all required clinical information prior tothe video consultation. The result of this process has been fewerinappropriate referrals and a greater understanding of the clin-ical data needed to diagnose, treat, and monitor complex med-ical conditions over video-based telemedicine. A case study willbe presented to illustrate the process developed.

P89STANDARDIZATION OF DERMATOLOGY CASEPRESENTATION FORMS FOR TELEDERMATOLOGYM. A. O’Reilly, MD,1 A. E. Burdick, MD, MPH,2 J. Lauman,BS,3M. E. Goldyne, MD, PhD,4 A. Papier, MD,5 Marta J. Petersen,MD1

1Department of Dermatology, University of Utah, Salt Lake City, UT;2Department of Dermatology, University of Miami, Miami, FL;3EMERG, Department of Dermatology, University of Utah, Salt LakeCity, UT; 4Department of Dermatology, University of California, SanFrancisco, CA; 5Department of Dermatology, University of Rochester

Teledermatology presents great promise for improving patientaccess to specialized skin care. The need to establish standardsfor case presentation with respect to content as well as imageshas been discussed by many of the leaders in teledermatology.Multiple objectives could be met with an appropriately adaptableformat for these interactions. A minimum standard content forencounters and images would help ensure consistent quality ofcare. A uniform approach to case presentation may also help ad-vance future research by facilitating data acquisition. Archives ofteaching cases could also be extrapolated from such a format. Asubgroup of the ATA Special Interest Group in Teledermatology(SIGT) proposed reviewing established protocols with the aim ofcreating a document for use in teledermatology consults. We sub-sequently reviewed protocols from military and civilian acade-mic programs, as well as those used in community and correc-tional settings. A list of minimum components required wassynthesized. A “Short Form” for routine cases and a “Long Form”for more complex cases or for teaching cases are presented.

P90TEACHING THE BASICS OF TELEMEDICINEDon McBeath, BA, Shannon Kennedy, MBA, Jon Phillips, BSTexas Tech University Health Sciences Center, Lubbock, TX

Over the last few years, telemedicine has become an extremelycomplicated scenario of technical, clinical, and regulatory inter-actions. Many health care policy makers and administrators lackthe basic knowledge to make informed decisions regardingtelemedicine. Seeing a need for a “basics” course on telemedi-cine, the Texas Tech Telemedicine Training Center developed a“Telemedicine 101” course to address the needs of people inter-ested in getting involved in telemedicine but not ready for someof the other more advanced technical and clinical courses available.

The eight-hour course, which spans two days, targets:1) Clinical personnel who would like to utilize telemedicine

as a tool for practicing medicine,2) Health care administrators who see telemedicine as a means

for enhancing service offerings, and,3) Community leaders and policy makers who want to learn

how telemedicine can be a strategy for addressing health care ac-cess.

The course serves as an excellent precursor for the level ofpresentations at meetings of the American Telemedicine Associ-ation. This presentation describes how the course was developedto meet the educational needs of the targeted audience, as wellas strategies for marketing the course.

P91ELECTRONIC TRANSMISSION OF ECHOCARDIOGRAMSTUDIES BETWEEN THE CLEVELAND CLINICFOUNDATION (CCF) AND HILLCREST HOSPITALDaniel Murphy, MD, Bob Mobley, Sharon Plona, RN, Neil Mehta,MDThe Cleveland Clinic Foundation, Cleveland, OH

Managed care has led to development of cost-efficient health carenetworks with fewer sub-specialists in one central location. A

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Cleveland Clinic Health System hospital lacks a pediatric cardi-ologist despite busy obstetric practice. Neonates with suspectedcongenital heart defects (CHD) had echocardiograms done whichwere sent via courier to main campus for review resulting in adelay in diagnosis / treatment. If special views were required,neonate needed to be transferred for further testing. Neitherphysicians nor technicians were satisfied with this arrangement.The 2 sites were linked using an Intel Team Station and tripleBasic Rate Interface lines of 384 Kbps. Neonatal echocardiogramsare now reviewed in real-time by a pediatric cardiologist whodirects the study, instructs the sonographer via voice link. Weevaluated this program using the first 90 neonatal echocardio-grams transmitted. All cardiac diagnoses made via telemedicinewere subsequently confirmed by follow-up echocardiography.There were no unnecessary hospital transfers and no transfersfor diagnostic purposes. Physician satisfaction and the expertiseof the echocardiographic technician were enhanced due to liveinteraction. Transmitted ehocardiogram quality was satisfactory.

Conclusion: Telemedicine is a useful tool for evaluation of sus-pected CHD: Current managed care climate is ideal for extensiveuse of this technology.

P92PRELIMINARY DATA ANALYSIS OF AVIATIONMEDICINEJeanette Rasche, MS, LTC Joe McKeon, MD, MPH, Colonel War-ren Whitlock, MD, Colonel James McGhee, MD, MPHCenter for Total Access, Fort Gordon, GA

While it is intuitive that distance-learning is an economical al-ternative to resident-based training, the effectiveness of a com-puter-based distance-learning program for medical educationhas not been studied. A study conducted by the Center for To-tal Access (CTA) and U.S. Army School of Aviation Medicine(USASAM) objectively determines the effectiveness of web-basedtraining for aviation medicine. In phase one, classes of flight sur-geon and flight medic students at USASAM were split into twogroups, one receiving a didactic lecture, and the other receivedon-line training. Preliminary data revealed no statistical differ-ence in mean test scores between the two groups, however, thedistance learning group achieved greater than a two-fold savingsin contact time. Based upon this data, specific medical modulesare as effective as classroom lectures and appear to be less timeintensive. The CTA and USASAM are committed to continuinga methodical approach to the development of a successful dis-tance-learning curriculum. Utilizing the scientific method, thelessons that can be effectively delivered on-line, and whichcourses require hands-on training at USASAM will become ap-parent. Lessons learned from Aviation Medicine Training onlinemay be applied to other medical distance learning initiatives.

P93REMOTE INTENSIVIST CONSULTATIONS TO CARESPECIALIST TO TREAT CRITICALLY ILL ANDUNSTABLE PATIENTSThomas T. Carmody, MAJ, MC, MD,1 Daniel B. Rayburn, PhD,2

Ernst A. Hoffstetter, MS,3COL Ronald K. Poropatich, MD3

1Thoracic Surgery Service, Department of Surgery, Walter Reed ArmyMedical Center, Washington, DC; 2Telemedicine Directorate, WalterReed Army Institute of Research, Washington, DC; 3Telemedicine Di-rectorate, Walter Reed Army Medical Center, Washington, DC

A limited number of intensive care specialists are available totreat critically ill and unstable patients who present to smallermedical facilities. Previous research documents the importanceof the intensivist consultation in the intensive care units. Con-sultations by an intensivist have been shown to reduce mortal-ity, decrease lengths-of-stay, and improve resource management.

Through the use of TeleMedicine Technology, we will determinethe efficacy of using a remote intensivist for medical consulta-tions of critically ill patients. In the current study, an intensivist,who is uninvolved in on-site care of the patient, conducts remoterounds from a central observation point. Real-time physiologicsignals, laboratory data and video are displayed at a central ob-servation room remotely located from the intensive care unit. The“remote intensivist” maintains a record of diagnostic findingsand therapeutic recommendations. Following the patient’s dis-charge, the diagnostic findings and therapeutic recommenda-tions of the “remote intensivist” are compared to those preparedon-site. Preliminary results comparing “remote rounding” withtraditional, on-site, care suggest strong diagnostic and thera-peutic concordance. The results of this study are to be presented.

P94USE OF SATELLITE TECHNOLOGIES FORHUMANITARIAN PURPOSEAntonio Guell, MD, CNES, Nicolas Poirot, MD, René Rettig, PhDMedes, Toulouse, France

Humanitarian purposes are first aims for practitioners educatedand trained to give accuracy response to health need of humanbeing. But for victims of crisis or disaster, they have to be ableto practice in very bad conditions. Satellite technologies seembetter than others for crisis and disasters because they can be op-erated anywhere, anytime. But biomedical industry and health-care organizations must be strongly involved to develop newpractices using space technologies.

MEDES is involved now to develop new applications as ex-perimental practices to assess efficiency of new productsprocessed by combined team of laboratories, industrial and prac-titioners:

a) Tele-epidemiology, merging different kind of data, is ableto support health care management and public health care pol-icy against epidemia related to environmental conditions. Inhealth field it’s a real breakthrough.

b) With tele-expertise we are confronted with new tools, de-pending on special know how to combine telecommunication,biomedical device and medical practice.

The two applications are working with mobile tele-medicinestation interfaced with multiple biomedical devices associated topalm technologies.

P95SUCCESS AND FAILURE OF A VA-COMMUNITYTELEMEDICINE NETWORKEdward D. Renner, PhD, MPH, Cynthia DubordVA Medical Center, Fargo, ND

The Fargo VAMC evaluated the use of telemedicine for deliveryof health care services to rural areas of North Dakota by utiliz-ing a community health providers network and clinics. The co-operative project involved two-way fully interactive electroniccommunication between geographically strategic rural clinicsand the VA Medical Center. Although health care providers andpatients were very satisfied with the interactive system in eightypercent of the three hundred conferences completed, the systemdid not meet expedited cost-effective utilization. The major ob-stacles were physician reluctance to utilize the telemedicine op-portunity and lack of administrative support. Lessons learnedwere that to initiate a successful telemedicine program the in-teractive video equipment must not be separated geographicallyfrom the clinic area and must be integrated into patient care clin-ics. In addition adequate and trained personnel must be assignedto the program rather than telemedicine being assigned as an-cillary duty. Authority must be obtained to schedule patients intotelemedicine clinics if they meet established criteria and consentto telemedicine care. Do not rely on physician scheduling. It is

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strongly advised a Telemedicine Advisory Committee consistingof key personnel from high application areas be established andcharged with obtaining realistic goals of telemedicine utilization.Establishment of a successful telemedicine program requires acommitment from administrative and medical services. Provid-ing telemedicine services without a clear understanding of therequirement it involves will not be cost-effective.

P96OPERATIONAL CONSIDERATIONS WHEN STARTING ATELE-HOME CARE PROJECT: FUNDING ASPECTSSusan G. Slater, RN, BSN,1 Holly Russo, MS, BS,2 Robert Mac-Donnell, Esq.11Telemedicine Solutions in Healthcare-Pittsburgh Regional Office, Cor-porate, Atlanta, GA; 2Tele-Health Consultant, Juno Beach, FL

Legal and regulatory implications of initiating a telemedicineproject in a home care setting are complex and varied, as theyare in telemedicine programs generally. These implications in-volve not only the legal and regulatory structure generally ap-plicable to telemedicine activities, but also varied and unique im-plications for the home care organization’s relationship with itspatients. The practical effect of these implications, the home careorganization’s design and operation of its program, are the keyto solutions to many of the issues raised by a telemedicine pro-ject. These solutions, however, require creative thinking and or-ganization patterns which vary from the norm. The presentationwill discuss the legal and regulatory aspects of licensing, multi-state practice, reimbursement, and liability. In addition, practi-cal solutions to organizational and operational aspects of atelemedicine program within the legal and regulatory contextwill be explored. Telemedicine can offer significant economic ad-vantages to home care organizations; however, the design andimplementation of a telemedicine program to comply with legaland regulatory requirements must be viewed critically and cre-atively in order to capture the full economic benefit of this newtechnology.

P97IMPACT OF TELEMEDICINE ON THE PRACTICE OFPEDIATRIC CARDIOLOGY IN A COMMUNITYHOSPITALCraig Sable, MD, David Kushner, MD, Melissa Fromm, Gail Pear-son, MD, ScD, Eric Quivers, MD, Russell Cross, MD, LorraineSchratz, MD, Susan Cummings, MD, MPH, Gerard Martin, MDChildren’s National Medical Center, Washington, DC

Real-time telemedicine transmission of neonatal echocardio-grams is used to evaluate newborns with suspected heart dis-ease.

Methods: Desktop computers (ViTelNET, Inc. McLean, VA), ca-pable of transmitting live echocardiograms over 3 ISDN telephonelines, were installed in the neonatal units of 2 community hospi-tals. Studies were interpreted, additional views suggested, andmanagement recommendations made by a pediatric cardiologist 15miles away. Accuracy, patient care, echocardiography utilization,referral patterns, time, and revenue were analyzed prospectively.

Results: 500 telemedicine transmissions were performed in 364patients over 2 years. Diagnoses included congenital heart dis-ease (n � 123) and patent ductus arteriosus (n � 86). Videotapereview confirmed diagnoses in all studies. Telemedicine had animpact on patient care in 252 studies. Utilization of echocardio-graphy before (36/1,000 births) and after (42/1,000 births)telemedicine installation was similar. The percentage of neona-tal echocardiograms that were interpreted by our practice in-creased from 53% to 84% (p � 0.001). Teleconference time aver-aged 20 � 7 minutes and resulted in an estimated timesaving of4.2 person-hours/week. Hospital charges from echocardiograms

and patient referrals (�$3,000,000) greatly exceeded the total costof telemedicine.

Conclusion: Neonatal teleechocardigraphy is accurate, im-proves care, increases referral of patients, improves cardiologisttime management, is cost-effective, and does not increase uti-lization of echocardiograms.

P98TRAINING TELEMEDICINE CONSULTANTSStan Saiki, MD, David Huhta, Michael Van Platen, Jana Hall,PhD, Richard Friedman, MDUniversity of Hawaii School of Medicine, Honolulu, HI

Clinician buy-in and investment is central to the success of anytelemedicine system. Clinicians must be comfortable that findingsachieved during a telemedicine consultation are the same as thosethat would occur during a real-time face-to-face encounter.

The University of Hawaii Telemedicine Group has developeda telemedicine orientation program held within a clinical labora-tory environment. The program places the clinicians and othermembers of the telemedicine team in “orientation” clinical en-counters. Telemedicine sending and receiving systems are set upin different rooms within the clinical laboratory. Trainees playingthe role of “consultants” are located in the consultation room. Theypractice their skills at communicating over telecommunicationslinks, assessing clinical information provided by the telemedicineperipheral devices and directing extenders in the examinationroom to assist in the examination of standardized patients. Uponcompleting the teleconsultation the trainee moves into the exami-nation room with the “patient” to confirm that his or her impres-sion over the telecommunications links are validated in the face-to-face visit.

Most participants require only two or three such exercises tobecome comfortable using the technologies. Disciplines such aspsychiatry, where there is less physical contact with patients, pre-dictably require less training. Disciplines, such as cardiology andgastroenterology, which require more intensive use of telemed-icine peripherals, require more training time.

P99PERCEPTUAL DISABILITY SCREENING IN AN URBANUNDERSERVED ELEMENTARY SCHOOL CLINIC VIATELEMEDICINEJade S. Schiffman, MD, Jerome Rosner, OD, Gina G. Wong, OD,Laura Kennedy, RN, MSN, LPNP, Laurel Marshall, OD, ReginaAdams, CMA, Rosa A. Tang, MD, MPH, Maria CastilloUniversity of Houston, Houston, Texas

Perceptual Disorders in children are common. Once a screeningexam detects a disability, it can be further analyzed by additionaltesting. Specialists in interpretation of these tests can then discussthe findings with both the teacher and parents and create a teach-ing strategy best suited for the individual student. Our experiencewith the analysis of test results through telemedicine and the in-terview between parents, teacher and child on-line with the per-ceptual disability specialist will be presented. Examples of teach-ing modifications that can be implemented will be discussed.

P100TELENURSING AND TELEMEDICINE: FINDINGS OF AUS STUDY OF THE EMERGING PROFESSIONAL ROLELoretta Schlachta-Fairchild, PhDiTeleHealth Inc., Frederick, MD

Telenursing is the use of telehealth technology to deliver nursingcare and conduct nursing practice (Schlachta & Sparks, 1999). Te-lenursing is emerging as a new role. Role stress asociated withnew nursing roles impacts individual patients and the largerhealthcare organiation, causing turnover, burnout, loss of conti-

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nuity of care and loss of operational expertise. As with manyemerging technologies, nurses assume increasingly complex rolesand responsibilities. As telemedicine proliferates, the role ofnurses in operationalizing and improving the telemedicineprocess will take on more and more importance. It is importantto identify issues related to use and integration of telemedicineinto nurses’ roles in order for telemedicine to flourish.

This presentation reports findings of a descriptive researchstudy, which used a web-based survey of US telenurses (N �

196) during Summer 2000. The purposes are to:1) Describe to telenurses’ professional role(s), characteristics,

and US strategies for nurse competence and patient safety.2) Measure & Predict—telenurses’ characteristics, work satis-

faction, role stress, role ambiguity and role conflict.3) Recommend—strategies for selecting and retaining te-

lenurses for telemedicine programs, companies and healthcareorganizations.

P101HOW TO DEVELOP SOUND PARTNERSHIPS FORSUSTAINING COMMUNITY-BASED TELEMEDICINESERVICESDeborah E. Seale, MA, Sally Sue Robinson, MD, FAAP, AlexiaGreen, RN, PhD, Glenda Walker, RN, PhD, Bobby Berg, RN,MSN, PNP, Christina Esperat, RN, PhD, CSFNP, Patty Ellison,MSN, RN, CFNP, Michael Chalambaga, BS, BAUniversity of Texas Medical Branch, Galveston, TX

Telemedicine is inherently a collaborative enterprise. There has tobe someone on each end of the line willing to place the call and/oranswer it. Consequently, the success of telemedicine rests on soundrelationships and effective communication. An expert with overseven years experience in developing collaborations and partner-ships for telemedicine will share proven techniques for identifyingthe necessary champions to develop, operate and sustain telemed-icine services. Techniques will be shared for building “grassroots”support at the organizational and community levels as well as gain-ing the support of upper level leadership in the organization andcommunity. This “ground-up,” rather than “top-down” approachassures that once the “deal is sealed,” the leadership understandsthe risks and the opportunities and the people on the ground floorhave the resources and dedication to succeed. Three case studieswill be presented in which these techniques were applied and suc-ceeded. One case study involves a regional network of 7 rural hos-pitals linked to a community college and regional hospital. The sec-ond is an academic health center linked to the nursing componentsin two universities. The third involves an academic health center,two universities and five public schools.

P102TELEMEDICINE IN RURAL GUATEMALA: A CASE STUDYJames M. Shanahan, BS, Gerardo Cabrera-Meza, MD, YadinDavid, PhD, Larry Jefferson, MD, John E. Kenna, BS, Doug Suell,MD, Nancy Wang, MEd, MAThe Center for TeleHealth, Houston, TX

One of the great promises of telemedicine is the ability to en-hance patient care in rural areas where subspecialty medical re-sources are less likely to be available. In September, 1999 TexasChildren’s Hospital in Houston, Texas, the Fundacion Semillasde Esperanza and the Hospital Infantil de Dr. Gustavo Casta edaPalacios, near Zacapa, Guatemala initiated a telemedicine pro-ject in which local physicians at the rural hospital site could sub-mit complex patient cases to sub specialists at the academic med-ical center. This presentation examines the planning, logistics,opportunities and results of this initiative. Using PC based hard-ware, store-and-forward software, a digital camera and clearlydefined operational protocols, this initiative demonstrates howexpertise typically found only at academic medical centers can

be effectively and economically conveyed to rural and under-served areas where such expertise is sorely needed.

P103RESEARCHING THE FEASIBILITY OF TELEMEDICINETECHNOLOGY FOR USE IN EMERGENT AND NON-EMERGENT ENVIRONMENTSMartha Sheely, RN, BSN, CCM,1 Randall Spears, BS2

1Mercy Home Health Services, Springfield, PA; 2Center for Disaster& Humanitarian Assistance Medicine, Bethesda, MD

A rapid response is vital to a patient’s recovery, especially in thefirst hour after a trauma. Having the ability to fully assess a pa-tient’s condition during that time enables a medical provider tomake an expedient decision regarding the provision of care.However, patients are often in remote locations with limited ac-cess to onsite health care professionals.

Mercy Home Health Services conducted a research projectfunded by a Federal grant from the Department of Defense to ex-amine the use of remote physiologic data monitors in the non-emer-gent home care setting. The patient population included CHF andopen-heart surgical patients. Medical devices collected vital signs,pulse oximetry, heart and lung sounds, and an ECG. A two-wayvideo camera provided visual contact. Data and video were trans-mitted through the patient’s phone line using a laptop computer.The research includes an evaluation of the accuracy of data col-lected compared to the actual home care visit made that day. Thelevel of training required and teaching tools needed for nurses andvolunteers will be reviewed. Additionally, the acceptance of thistechnology by the community and medical profession as an inte-gral part of health care will be discussed.

P104CENTER FOR NATIVE AMERICAN TELEHEALTH ANDTELEEDUCATIONJames (Jay) Shore, MD, MPHUniversity of Colorado Health Sciences Center Department of Psychi-atry, Denver, Colorado

The Center for Native American TeleHealth and TeleEducation(CNATT) is the telecommunications component of the Division ofAmerican Indian and Alaska Native Programs at University of Col-orado Health Sciences Center (UCHSC) Department of Psychiatry.CNATT organizes and focuses technological resources for NativeAmerican Health from an array of telecommunications services atthe UCHSC to offer education, resources, and training. CNATTalso monitors impact assessment of these telecommunications ser-vices. CNATT facilitates these activities through two services. Thefirst is the Indian Telehealth Network, which is composed of 9 sitesin Indian Communities throughout the Western United States. Thistelehealth network provides consultation/liaison services, distancelearning programs, and helps to facilitate rapid communication andlinkage between these Indian Communities and the UCHSC. Thesecond is the World Wide Web sites of the American Indian andAlaska Native programs, which offer information disseminationand archive retrieval. These programs are directly relevant to theculturally informed diagnosis, epidemiology, treatment, and pre-vention of physical, alcohol, drug, and mental health problems thatcommonly occur among American Indians and Alaskan Natives.The CNATT programs provide an important model of utilizingtelehealth to improve services for under served populations.

P105IDENTIFYING UNDIAGNOSED DEMENTIA INWASHINGTON STATE VETERANS HOMES VIATELEMEDICINE ASSESSMENTMolly Shores, MD,1,2 Elaine Peskind, MD,1,3 Rhonda Williams-Avery, PhD,1 Peggy Ryan-Dykes, ARNP,1,4 Bless Mamerto, MD,5

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Mercedes Zweigle, MD,5 Pat Palmer, RN,5 James Petrulli, RN,6

Tom Lampe, MD,1 Paul Nichol, MD1

1VA Puget Sound Health Care System, Seattle, WA; 2Geriatrics Re-search, Education and Clinical Care (GRECC); 3Mental Illness Re-search, Education and Clinical Center (MIRECC); 4Geriatrics and Ex-tended Care (GEC), Washington Veteran’s Home at Orting; 5WashingtonVeteran’s Home at Retsil; 6Washington Veteran’s Home at Orting

Overview: Dementia is a significant problem in aging, which is fre-quently unrecognized. Telemedicine assessment for dementiawould make specialty consultation available to remote sites, whichwould likely improve the diagnosis/management of dementia.This study will compare telemedicine and clinical examinations toestimate the reliability of telemedicine in diagnosing dementia andthe acceptability and costs of telemedicine versus usual care.

Methods: Veterans at two Washington State Veterans homes,who screen positive for dementia and consent to participate, willhave a telemedicine examination for dementia. The reliability ofthe telemedicine assessment will be estimated by comparing itto a clinical examination by a geriatrician who is blinded to thetelemedicine assessment. Patients with dementia will be ran-domized to follow-up via telemedicine or usual care. Referringstaff from the outside facility will have access to the computer-ized medical record system (CPRS) at the tertiary care facility,which includes progress notes, laboratory and imaging data.

Results: Reliability of telemedicine diagnosis, staff satisfactionwith telemedicine and CPRS, and time and cost of patient care.Baseline data on attitudes of referring staff indicates that 53%have never used CPRS and that 80% have had no experience withteleconferences. Staff expressed frustration with the current re-ferral process, mean score of 2.17 (where 10 � high satisfaction)and expressed positive attitudes towards telemedicine, meanscore of 3.9 (where 5 � most favorable). Outcome data ontelemedicine dementia assessments, costs and satisfaction willsubsequently be presented.

P106TELEMEDICAL REHABILITATION: AN EMERGINGTECHNOLOGYGordon Silverman, PhD,1 Joseph Brudny, MD,2 Paulette Gage,PhD3

1Department of Electrical & Computer Engineering, Manhattan Col-lege, Riverdale, NY; 2Clinical Associate Prof. of Rehabilitation Medi-cine, New York University School of Medicine, New York, NY;3PhysMed, Inc., Somerset, NJ

Remote delivery of neuromuscular re-education aided bybiofeedback has recently become feasible with the confluenceof high-speed network technology and low cost computers(PCs). A Local Area Network (LAN) or Internet-based networkincluding a teleconferencing communication channel are con-figured to enable a therapist to remain in concurrent contactwith several patients, supervising their rehabilitation in realtime, and provides resources for detailed patient records quan-tifying functional gains. An array of sensors collects informa-tion from each patient and relays it to the local PC for integra-tion and display of attempted, as well as desired movementpatterns. The infrastructure includes capability to provide realtime feedback for shaping a patient’s motor control of a dys-functional limb. Feedback facilities include: virtual images ofthe patient’s limb that mirrors actual movement; oscilloscopictraces depicting target (response goals) and actual responses;and auditory feedback to supplement graphical information. Inaddition, the system software can be extended to determine thenature of movement disorders, select an appropriate trainingprotocol, and assist in the shaping of the patient’s functionallevel of performance. The system addresses the challenges facedby the delivery of rehabilitation services—improved evidence-based outcomes at reduced cost.

P107OPERATIONAL CONSIDERATIONS WHEN STARTING ATELE-HOME CARE PROJECT: CLINICAL ASPECTSSusan G. Slater, RN, BSN,1 Holly Russo, MS, BS,2 Robert Mac-Donnell, Esq.11Telemedicine Solutions in Healthcare-Pittsburgh Regional Office, Cor-porate, Atlanta, GA; 2Tele-Health Consultant, Juno Beach, FL

Initiating a Telemedicine project within a home care setting takesmany hours of research and planning. There are many details,which must be thought through, in order to have a telemedicineprogram run smoothly. Telemedicine is a great tool to augment thecare traditionally provided by the home care agency. The staff willfind that the patients are very receptive to this tool, and will lovethe flexibility telemedicine offers the staff to manage their care. Allmembers of the home care agency team; from the non-clinical sup-port staff to the clinical staff and administrators, need to work to-gether to make this type of project work. It is very important tohave a telemedicine philosophy within the organization, to get allof the staff to embrace the project. The program implementationissues that will be discussed are: equipment selection, tracking, andmaintenance; staff training, patient training, peripheral device use,documentation, outcome measurements, and coordination of careusing a (TCM) telemedicine case manager.

P108CARDIOLOGY NETWORK—PEOPLE AND TECHNOLOGYIN CONCERTMark Starling, MDVA Ann Arbor Health Care System, Ann Arbor, MI

The Michigan VA hospitals recognized the need for significantchanges in the care delivery model for cardiac services. With acentral tertiary referral site in Ann Arbor, three other major VAhospitals several hundred miles away, and remote clinic loca-tions, roadblocks to streamlined care exist.

The lack of information flow, access to care, information, ex-pertise, scheduling, management of reports and images, refer-rals, consults and transfer processes are problematic. Proceduresare often not done at remote sites due to lack of technical ex-pertise, or are repeated at the referral center due to poor imagequality, requiring patients to travel. Referral processes are dis-jointed. Schedules are not widely available. There are problemswith availability of images and reports. Inadequate mechanismsare in place for return of patients and appropriate follow-up careand no utilization of clinical pathways or disease managementalgorithms. Six of the top ten DRGs at the central site are for car-diac conditions. Demographic profiles of the areas surroundingthe facilities demonstrated a large underserved population of pa-tients at high risk for cardiac disease.

Solutions being implemented:1) Care navigation: referral procedures, clinical pathways, and

disease management algorithms to streamline the continuum ofcare; 2) Digital connectivity for all cardiac laboratory modalities:ECG, catheterization, echocardiography, electrophysiology, Holtermonitor, stress test; 3) Information systems for network-wide useto accommodate scheduling, reporting, image management, notes,CPT coding, billing; 4) Telecommunication systems: telementoring,teleclinic, teleconferencing and telereferral/teleconsultation.

P109TELEMEDICINE IN GREENLAND—PRELIMINARYEVALUATION RESULTSThomas Stensgaard, MDNuuk Primary Health Care Clinic, Greenland Home Rule, Nuuk,Greenland

In the spring of 1999 a business plan for telemedicine in Green-land was approved. This business plan includes an evaluation

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plan describing the extent and kind of evaluation that should beincorporated in the project. The evaluation includes the follow-ing criteria: expectations and reactions of the users, satisfactionamong patients, logistics, organization and technology, medicaloutcome, waiting time, travel activity among patients, economy,transferring of competence and recruiting/retaining of staff. Theparameters were defined with a view to what answers it seemspossible to obtain in the Greenlandic environment, i.e. factorslike geography, staff, economy etc. So was also the case with themethods chosen to collect data: questionnaires, logs and inter-views. Evaluation appears as a health technology assessment andwas developed by an economist, a sociologist and a medical doc-tor in cooperation, with great an valuable help from the NationalCenter for Telemedicine in Tromsø, Norway.

The first results from the evaluation will be presented.

P110PROTOCOLS FOR E-MAIL TELEOPHTHALMOLOGY:HOW TO ESTABLISH GUIDELINESRosa A. Tang, MD, MPH, Jade S. Schiffman, MD, Gina G. Wong,OD, Sonali Singh, MD, John Horna, BA, Regina N. Adams, CMAUniversity of Texas Medical Branch at Galveston, Houston, TX

Surfing the web for health care information is so common. Useof the Internet in the U.S.A. increased at a rate of 60% from 1998to 1999. As patients come to rely on e-mail as an essential com-ponent of communication, the doctor-patient relationship facesnew challenges and new risk exposures. A comprehensive e-mailpolicy with protocols has been devised and tested in over 50 casesand found to be a useful tool for patient communication strate-gies to ensure that this technology is used optimally for healthcare queries is discussed.

P111RETINAL SCANNING DISPLAY FOR THE MILITARYMEDICAL INFORMATICS PERSONAL DATA ASSISTANTChristine M. Thero, BSEE, MSEE, MBA,1 Gary R. Gilbert, PhD,2,3

John R. Choate, BA1

1Microvision, Inc., Bothell, WA; 2United States Army Medical Re-search & Materiel Command (USAMRMC), Telemedicine & AdvancedTechnology Research Center (TATRC), Ft. Detrick, MD; 3Universityof Pittsburgh Katz Graduate School of Business

Force medical protection is the collective effort of the militaryto improve the survivability of its forces through health servicessupport. Access to immediate information can enable informedmedical decisions, reduce the number of errors, and improvehealth care. Likewise, a medical informatics tool that captures,transmits and analyzes patient information at the point of carecan potentially improve immediate diagnosis and treatment, aswell as follow up care during evacuation, hospitalization, andconvalescent care. Telemedicine technology research aimed atthe wireless Personal Data Assistant (PDA) is intended to pro-vide health care providers with real-time access to criticalhealthcare data via a wireless, personal display, medical infor-matics tool and to collect more accurate and more timely pa-tient data even at the first responder point of encounter. Wepresent our work in miniaturizing and integrating a daylightreadable laser retinal scanning display as a hands-free user vi-sual interface to a military medical PDA. The retinal scanningdisplay system is a very high brightness, “see-through,” high-resolution human wearable computer display system. This headworn display enables the user to view electronic informationfrom precise measurement and graphic data to patient recordsin all lighting conditions without blocking the user’s normalfield of vision, and it leaves the user’s hands free to performpatient care.

P112USING TELEMEDICINE AND WIRELESS TECHNOLOGYTO IMPROVE DIABETIC OUTCOMES IN POORLYCONTROLLED PATIENTSRobert A. Vigersky, MD,1 Donna Thomas-Wharton, MPA, Doc-toral Student,1 Wendy Biddle, PhD, CFNP,2 Amy D. Filmore,CRNP3

1Walter Reed Army Medical Center, Department of Medicine, En-docrinology Service (7D), Washington, DC; 2Old Dominion Univer-sity, School of Nursing, Norfolk, VA; 3Diabetes Institute, Walter ReedHealth Care System Endocrinology Service (7D), Walter Reed ArmyMedical Center, Washington, DC

There are currently over 16 million diabetics in the United States.Diabetes is particularly difficult to control because of frequentfluctuations in blood glucose, requiring frequent (often daily) ad-justments in insulin and/or other diabetic medication because ofvariation in diet, physical activity, and stress. Hemoglobin A1Clevels reflect the three month average of blood glucose and areused as clinical markers of effective therapy. We propose usingtelemedicine technology to more frequently monitor blood glu-cose levels, make daily therapeutic adjustments, and assess theseeffects upon hemoglobin A1C levels. Diabetics will record andclinicians will monitor daily blood glucose levels, diet, and phys-ical activity. Clinical responses are specific to current conditionsand include menu suggestions and medication adjustments. Weare currently studying the efficacy of this telemedicine technol-ogy on 600 diabetics from the Diabetes Institute at the WalterReed Army Health Care Center. Diabetics are randomly assignedto one of three technology groups or a standard care group,which serves as the control. Patients are to be studied for 6-months. Patient compliance, Hemoglobin, the number of majorand minor hypoglycemic episodes, emergency room visits, hos-pital admissions, and the development of new diabetic compli-cations will be statistically analyzed for each group.

P113EVALUATING PRACTITIONER ATTITUDES TOTELEDERMATOLOGYJohn Togno, MBBS FRACGP, Joe Hovel, RNMonash University Centre for Rural Health, Bendigo, Victoria Aus-tralia

Teledermatology is a technically proven method for supporting re-mote practitioners in the diagnosis and management of skin con-ditions. However, there is relatively little evidence of the accept-ability of teledermatology by family medical practitioners,dermatologists and their patients. This paper presents preliminaryfindings on the attitudes of family medical practitioners, derma-tologists and their patients based on an evaluation of telederma-tology consults in rural areas of Victoria, Australia over a period ofthree months. These regions have very poor access to face-to-facedermatology services, and the development of teledermatology ser-vices that are acceptable to all users is the key to improving accessto dermatology services in rural areas. The evaluation takes into ac-count issues including ease of use of digital cameras, the softwareand hardware required to transmit images, image quality, responsetimes for dermatology opinions and patients’ attitudes to the useof the service for management advice for their skin conditions (witha particular emphasis on cost and time effectiveness).

P114EXTENDING THE GGTS CONSULT BROKERLuis G. Vargas, PhD,1 Jerrold H. May, PhD,1 William G. Jacobs,1

Gary R. Gilbert1,2

1AIM Laboratory, University of Pittsburgh, Pittsburgh, PA; 2UnitedStates Army Medical Research & Materiel Command (USAMRMC),Telemedicine & Advanced Technology Research Center (TATRC), Ft.Detrick, MD

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At ATA 2000, we described a prototype decision aid to supportmatching up someone requesting a teleconsultation with some-one who could provide the desired assistance. That decision aid,the Consult Broker, was built using data from a teledental sys-tem maintained at TATRC. The Consult Broker is to be part ofthe Global Grid Telemedicine System (GGTS). A key part of theConsult Broker is its naive Bayesian classifier, which extractsfrom technical medical text information that can be used for theadministration and management of the teleconsultation. Thenaive classifier worked quite well for most areas of dentistry. Inthis talk, we discuss our experience in extending the Consult Bro-ker’s classifier to general medical problems, using a large(55,000�) surgical database. Certain areas of medicine are wellserved by the same approach that we used for dentistry, but amulti-level approach using the knowledge inherent in the ICD9and CPT hierarchies is particularly promising.

P115A VIRTUAL SURGERY MODEL: FUNDAMENTALS ONELECTRONIC ENDOSCOPIC OTOLARYNGOLOGY WEB-BASED SCENARIOJorge Alberto Velez B., MD, SHM, Carlos Alberto Gamboa M.,MDAsociacion Internet Salud Y Medicina, Colombia

*No abstract available.

P116CONFRONTING COGNITIVE ISSUES IN PHARMACY:CARING FOR DIABETIC PATIENTSMarcia Walker-Guy, RPh, MEDMedicognitive Solutions, Inc., Norcross, GA

The organization of healthcare has changed over the past twodecades. The goals of Pharmacy education have been contouredto meet this change. Historically, the pharmacist’s role consistedof the compounding and dispensing of pharmaceuticals. In re-sponse to the demand for a more skilled and knowledgeablepharmacist, the profession embraced the new philosophy andpractice of Pharmaceutical Care. Despite this achievement, grad-uates from most accredited pharmacy schools were equippedwith an abundance of facts, but very few skills to apply thesefacts. According to Spiro et al (1992), cognitive and instructionalneglect of problems, related to content complexity, irregularityand patterns of knowledge use leads to learning failures that takecommon, predictable forms. A feasible instructional strategy thatsupports the cognitive demands in pharmacy education andpractice will transcend those of traditional education.

P117ACCURACY OF STORE-FORWARD TELEDERMATOLOGYFOR DIAGNOSIS OF SKIN NEOPLASMSErin M. Warshaw, MD, Sandra K. Schmunk, BS, MA, HHSAVA Upper Midwest Network, Minneapolis, MN

We report the interim results of a study designed to assess thediagnostic accuracy of store-forward digital images of skin neo-plasms as compared to clinic diagnoses using histopathologicfindings as a gold standard. While preliminary studies haveshown the diagnostic agreement of teledermatologists and clinicdermatologists regarding most dermatologic conditions to becomparable to traditional, clinic-based visits, diagnostic accuracyand agreement of transmitted images of skin neoplasms may besub-optimal. This project is a comparative study of store forwardteledermatology and traditional, in-person encounters using a re-peated measures design.

Primary endpoint is diagnostic accuracy of skin neoplasmsvia store forward teledermatology as compared to traditionalclinic encounters. Secondary endpoints include diagnostic agree-

ment and appropriateness of management. In addition, we willevaluate present preliminary findings on teledermatoscopy, thetransmission of digital images obtained through a relatively newskin magnification device, for accurate diagnosis of pigmentedlesions. Malignant melanoma is one of the most common anddeadly forms of skin cancer. Patient survival depends on theidentification and removal of early, thin lesions. Any method,which improves patient access to dermatologists or increases theaccuracy of melanoma diagnosis, should enable earlier diagno-sis, thereby enhancing survival. Evaluation of technological pa-rameters, efficiency, cost-effectiveness and patient satisfactionwill also be reviewed. Potential benefits include improving andexpediting dermatology consults, reduction of direct and indi-rect costs, and improved access to dermatology services.

P118PATIENT SATISFACTION WITH TELEPSYCHIATRY VS.TRADITIONAL OUTPATIENT PSYCHIATRIC CARELydia E. Weisser, DO, Rhonda G. Vought, MDMedical College of Georgia, Augusta, GA

Patient satisfaction with outpatient treatment is often a concerneven with traditional methods of healthcare delivery. Over thepast 3 years, the Georgia Statewide Telemedicine Program hasdeveloped an on-going relationship with several rural sites toprovide continuity telepsychiatry clinics. These sites are locatedin Wrightsville, Athens and Warrenton, Georgia, where the pop-ulations served are primarily adult; however, there is also aChild/Adolescent clinic based in Waycross. Although patientshave directly and indirectly expressed a high degree of satisfac-tion with the level of care received, until now no formal attempthas been made to measure patient satisfaction with telepsychia-try vs. conventional psychiatric outpatient care. A questionnairewas developed by incorporating elements from the Mayo ClinicPatient Satisfaction Survey and the McLean Hospital Perceptionsof Care Survey. Additional elements specific to the telemedicineexperience were added. This survey was administered to ap-proximately 50� outpatients (or their parents) at the varioussites. Although data collection is on-going at this time, prelimi-nary results indicate that patients perceive their care to be at leastequal to that delivered by more traditional methods. New pa-tients as well as returning patients were included in this survey.

P119ON-DEMAND TRAINING FOR DEPLOYEDTELEMEDICINE APPLICATIONSCol. Warren Whitlock, MD, FACP, LTC Phylanne Prince, RN, EdKensinger; Gary Gilbert, PhDCenter for Total Access, Fort Gordon, GA

In a deployed military environment, telemedicine provides in-formation management for essential tasks of medicine, includ-ing clinical documentation, medical evacuation and identifica-tion of medical threats. The use of medical applications within adeployed environment has a demonstrated need for integratedtraining of military medical personnel. Cobra Gold 2000, a jointmilitary exercise simulation of a humanitarian relief effort, uti-lized a 6-point network where hardware, communications, andsoftware applications were evaluated under field conditions.Prior to deployment, training on the telemedicine applicationstook place at four different locations and was rated highly suc-cessful.

During the exercise, problems were encountered includedconfiguration and incompatibility errors. These errors resultedin limited WAN and LAN access. Only 14% of the participatingmedical personnel completed pre-deployment training oftelemedicine equipment.

Telemedicine skills require training for topics including: net-work security, authentication, network applications, technical

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analysis, medical application problem solving, and training datacollection methodologies. In addition to being on-demand, thetraining package must be multi-modality, and capable of cus-tomization for specific military mission requirements. The ap-plication server design utilized for telemedicine training duringmedical missions can be applied to civilian telemedicine train-ing efforts.

P120SPECIAL OPERATIONS MEDICAL DIAGNOSTICSYSTEM (SOMDS): SYNCHRONOUS DISEASESURVEILLANCE USING A WIRELESS APPLICATIONCol. Warren Whitlock, MD, FACP, Ron Packard, Gary Gilbert,PhD, COL Stephen Yevich, MDCenter for Total Access, Fort Gordon, GA

Historically, routine patient encounters accomplished in a de-ployed tactical environment are undocumented or not properlydocumented. Inadequate documentation of patient encountersdoes not provide an accurate visibility for disease surveillance.If all patient encounters were documented during the PersianGulf War a more complete picture of Gulf War Illness would beavailable today.

The MedSurv module, a component of the Special OperationsMedical Diagnostic System (SOMDS) is designed to collect spe-cific data elements at the point of care. MedSurv operates on ahand-held device functioning both synchronously and asyn-chronously with a centralized database. The utility of a wirelesstechnology platform will increase the likelihood for medics torecord field encounters.

Once recorded and downloaded to the centralized database,data mining can be easily accomplished. This approach will pro-vide increased disease surveillance during field conditions thateffect military readiness.

The development of disease surveillance and medical threatanalysis in a wide variety of deployed field environments pro-vides a rapid and accurate assessment of the field health care de-livery process. Lessons learned can be applied to civilian health-care: health clinic, nursing homes, home health and patienttransport.

P121HOME-BASED PILOT PROGRAM MONITORS: EFFECTOF AN INTERACTIVE TELEHEALTH DEVICE ONMANAGEMENT OF HEART FAILURENeil Mehta, MD, Sandra Wilkinson, RN, Christine Pierce, RN,CS, MSN, Robert W. Mobley, Sharon Plona, RNCleveland Clinic Home Care, Valley View, OH

Heart failure is the nation’s most rapidly growing cardiovascu-lar disorder and places a substantial financial burden on thehealth care system. Home health care has become an increasinglypopular venue of care for the management of this chronic illness.Statistics published by the National Association of Home Careidentify Heart Failure as the most common admission diagnosisfor patients age 65 and older. Non-compliance with the medicalplan of care is a well-documented factor in exacerbation of symp-toms and rehospitalization. This pilot will utilize a home-based,interactive, electronic device as a supplement to usual patientcare, to address key areas of the patients’ self-care. Data enteredby the patient is viewed remotely by the nurse. The pre-pro-grammed, portable device electronically communicates with thepatient to integrate: patient teaching, symptom recognition andreporting, and timed medication administration reminders. Inaddition to numerous pragmatic observations, the interventiongroup will minimally be compared to patients receiving standardcare for the following empirical data: 30 and 60 day rehospital-ization rates, compliance with weight monitoring, and reportedmedication compliance. This pilot is designed with a limited

sample size to evaluate the feasibility and potential value of im-plementing a large-scale study of statistical significance.

P122STEREOSCOPIC DIGITAL IMAGING AND ITS IMPACTON GLAUCOMA SCREENING AND MANAGEMENT VIATELEMEDICINEGina Wong, OD, Jade S. Schiffman, MD, OD, Regina Adams,CMA, Rosa A. Tang, MD, MPHUniversity of Houston, Houston, TX

Glaucoma is one of the most common causes of blindness andoften does this silently until the disease is end stage. Screeningfor glaucoma is difficult because to do so, one needs an excellentstereoscopic image of the nerve that can be done reliably and beperformed by a non-eye care professional in underserved sites.A new digital stereoscopic camera, the Discam, allows this tohappen. This camera will be compared with standard 35 mmstereoscopic images as well as the face-to-face exam. Stereoscopicdigital images with the Discam, allow screening and manage-ment of glaucoma through telemedicine.

P123BRINGING MEDICAL INFORMATION ASSURANCEINTO FOCUS FOR YOUWillie Wright, MBA1,2

1United States Army Medical Research & Materiel Command (US-AMRMC), Telemedicine & Advanced Technology Research Center(TATRC), Ft. Detrick, MD; 2SRA International Inc., Ft. Detrick, MD

What happens when we come face-to-face with unlimited infor-mation and computing power at the same time that the very no-tion of knowledge as an intangible is being challenged?

The Department of Defense Medical Services finds itself an-swering this question as it pertains to information assurance, af-ter identifying that the nation’s critical infrastructure needs pro-tecting.

Although the process and the connections that convert infor-mation to knowledge reside principally in people’s minds, thetools they use to make those connections—and the way in whichthey organize the information necessary to support their deci-sions—reside at the desktop. Therefore, these tools can easily bemade part of a corporate memory.

While not a panacea, the aggregation of information sourcesprovides added value by capturing the connections that makeup the value basis for most knowledge workers’ environments.

Risk Management Information Resource (RIMR) then becomethe foundation for starting to reverse the brain drain process. TheRIMR project expects to be proactive and make knowledge ac-cessible to all and not await the fate of the silent brain drain.

What’s RIMR?RIMR—knowledge management system that provides a sys-

tematic process for acquiring, creating, synthesizing, sharing,and using information, insights, and experiences to achieve or-ganizational goals.

P124TELEPATHOLOGY FOR ORGAN TRANSPLANTATION*Yukako YagiUniversity of Pittsburgh Medical Center, Pittsburgh, PA

*No abstract available.

P125E-PUBLISHING—THE PROVISION OF HIGH QUALITYHEALTH INFORMATION ON THE INTERNETPeter Yellowlees, MD, BSc, MB, BS, FRANZCP, MRC (Psych)MAPsS, MRACMUniversity of Queensland, Brisbane, Queensland, Australia

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One of the many revolutionary aspects of e-health concerns e-publishing on the internet. The author has published two e-books, one by self publishing at www.mightywords.com, andthe other through a traditional academic publisher, The Univer-sity of Queensland Press at www.uqp.uq.edu.au. This paper willreview various aspects of e-publishing, including the process ofwriting for the internet, which is very different from conven-tional writing, the need for a strong customer focus, the inclu-sion of multi-media into text, and the extra flexibility allowed bythe facility to change publications, and update them easily. Theimplications of the e-publishing revolution in health will be dis-cussed from a perspective of patients, clinicians, authors andpublishers and the way in which e-publishing will become a vi-tal part of e-healthcare delivery in future years will be described.

P126TELEMEDICINE IN BANGLADESH: A COMPREHENSIVEAPPROACH TO OVERCOME BARRIERS TOINTERNATIONAL TELECONSULTATIONSikder Zakir, MB, BSTelemedicine Reference Center Ltd., Dhaka, Bangladesh

Bangladesh is under-served both medically and technologically,which is further worsened by lack of telecommunication infra-structure. The introduction of telemedicine system and servicesis occurring in four phases. Phase I was completed with exten-sive research of the system keeping in view the barriers those ex-ists in developing countries. Phase II included detailed study,appropriate configuration and outsourcing of telecommunica-tion, equipment and medical resources. Phase III concluded byeducating concerned professionals in the systems and its out-come. Phase IV involves setup of the system and start of US-Bangladesh teleconsultation. This presentation gives a clear pic-ture of every phase with definition of barriers and possiblecost-effective solutions.

The detail study report was prepared for Telemedicine Ref-erence Center Ltd., which includes: 1) technology assessment andevaluation, 2) telecommunication infrastructure deficiencies andsolutions, 3) equipment outsourcing, 4) response of medical pro-fessionals, 5) needs assessment, 6) defining categories and typesof international teleconsultation and costing, 7) response of thegovernment machineries, 8) development of US-Bangladesh jointphysician teleconsultation programs, 9) reimbursement methods,10) business plan and 11) implementation procedures for ruraland international teleconsultation systems. Based on the reportTelemedicine Reference Center Ltd. is introducing cost-effectivetelemedicine system in Bangladesh on January 25, 2001.

P127A COMPARISON OF THE IRREVERSIBLE DCT ANDWAVELET COMPRESSION ALGORITHMS APPLIED TOMEDICAL IMAGESYongguo Zhao, PhD, Isao Nakajima, MD, PhD, Hiroshi Juzoji,PhDTokai University Medical Research Institute, Nakajima Laboratory Bo-seidai, Isehara, Kanagawa, Japan

Objective: JPEG 2000, the next ISO/ITU-T standard for still im-age coding, is about to be finished. Wavelet transform is the corestrength of the new standard. This paper evaluates the perfor-mance of JPEG 2000 irreversible compression algorithm by com-paring with the original JPEG standard. Image quality proper-ties including the NMSE and PSNR were assessed, and theimpact of JPEG 2000 coding algorithm was analyzed. The prin-ciples behind the wavelet-based JPEG 2000 were briefly de-scribed and an outlook on the application in medical imagingwas discussed.

Material and Methods: Ten grayscale radiographs and ten colorpathologic images were digitized, compressed, and decom-

pressed by both the original JPEG standard and by using a javaimplementation of JPEG2000 encoder/decoder developed by theJJ2000 group. The NMSE and PSNR of the images compressedby JPEG and JPEG 2000 algorithms were calculated at variouscompression rates. The results were plotted respectively andcompared with each other.

Results and Conclusion: It was found that JPEG 2000 irre-versible compression algorithm can achieve higher compressionefficiency with less error rate. There is a true improvement in theperformance of the new standard. The results of this initial ex-perience pave the way for further observer performance studies.

P128TELEMEDICINE IN DEVELOPING COUNTRIES:ACTIVITIES OF STUDY GROUP 2 OF THE IUTDEVELOPMENT SECTOR (IUT-D)Yongguo Zhao, PhD, Isao Nakajima, MD, PhD, Hiroshi Juzoji,PhDTokai University Medical Research Institute, Nakajima Laboratory Bo-seidai, Isehara, Kanagawa, Japan

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The International Telecommunication Union (ITU) has been ac-tively promoting the wide application of telecommunication so-lution in areas such as healthcare and education. It has set up anumber of pilot projects involving telemedicine throughout theworld. The ITU also sponsored the First World TelemedicineSymposium for Developing Countries in Cascais, Portugal on 30June–4 July 1997, and the Second Symposium held at BuenosAires, Argentine on 7–11 June 1999. Both were with great suc-cess.Within the ITU-D Study Group 2, the Rural Application Fo-cus Group (Topic 7) headed by Mr. Yasuhiko Kawasumi and itsTele-Health and Tele-Medicine Discussion Group chaired byProfessor Leonid Androuchko is working on providing recom-mendations and guidelines on telemedicine for developing coun-tries.

This paper highlights current activities with regard totelemedicine in and for developing countries. It reviews the cur-rent agendas on telemedicine of the Rural Application FocusGroup within Study Group 2 of the ITU. The special features andobstacles to deploy telemedicine in developing countries are an-alyzed and the feasible approaches based on successful cases aresuggested.