ORGANIZATIONAL STRUCTURE OF TELEHEALTH CARE:
AN EXAMINATION OF FOUR TYPES OF TELEMEDICINE SYSTEMS
A Dissertation Presented
For the Doctor of Philosophy
Degree
The University of Tennessee, Knoxville
Teresa Smith Welsh
August 2002
ABSTRACT
The purpose of this study is to make recommendations for a sustainable
telemedicine system by examining the structural attributes of telemedicine across
and within different types of organizations. A survey instrument with two
categories, background questions and evaluation questions, was developed and
used as a guide to interview eight key informants from four different types of
telehealth systems. The eight transcribed interviews were coded using NUD*IST
qualitative software. Research publications, archival documents, and government
reports were collected to triangulate, or cross check, interview data. Multi-case
study methodology was used as a guide to design the research, analyze date,
compare results, and make recommendations.
A telehealth typology is proposed as well as a simplified conceptual telehealth
model and a diffusion of telemedicine model.
While there are some structural differences among the different types of
programs, there are many more similarities. All receive funding from multiple
sources, and all employ a combination of full and part-time employees. Three
core staff categories include administrative, medical, and technical support.
Additional categories may include evaluation researchers and project
coordinators.
Major barriers to the development or maintenance of a telehealth system
are identified as telecommunication costs and lack of infrastructure; physician
ii
participation, both referring and providing; concerns about profitability and
liability; and lack of internal support and resistance to change.
Factors of organizational structure identified as conducive to growth and
sustainability of a telehealth network include: development of a statewide, multi-use
network; an advisory oversight group composed of key players in state government,
higher education, telecommunications, and healthcare educators; integration of the
network into desktop environments; multiple funding strategies; internal support and
marketing and external marketing.
Recommendations for developing, growing, and sustaining a teleheatlh
network are provided as well as recommendations for further research.
iii
TABLE OF CONTENTS
Chapter
Page
I.
INTRODUCTION ..................................................................................1
Problem Statement .......................................................................................2
Purpose of the Study ....................................................................................3
Research Method .........................................................................................3
Research Questions ......................................................................................4
Limitations of the Study...............................................................................5
II.
REVIEW OF THE LITERATURE ....................................................7
Telemedicine ................................................................................................7
Definition .........................................................................................7
Typology ..........................................................................................9
Origins and Development ..............................................................17
Research Literature ........................................................................19
Current Trends, Uses, and Benefits ...............................................22
Barriers to Implementation and Use ..............................................25
Federal Government and Telemedicine .....................................................26
Mal-distribution of Health Care Resources ...................................28
Federal Telemedicine Projects .......................................................31
Adoption of Telemedicine Technology .....................................................34
Patient Acceptance ........................................................................35
Provider Acceptance ......................................................................36
The Internet and E-Mail .................................................................38
Telemedicine Theory .................................................................................41
Cybernetic Model...........................................................................41
Diffusion of Innovations ................................................................45
Diffusion of Innovations in Health Care Organizations ................49
Critical Mass Theory......................................................................50
Case Studies, Surveys of Telemedicine Networks ....................................51
III.
METHODOLOGY ...............................................................................55
Case Study .................................................................................................55
Research Design.........................................................................................56
Unit of Study – Telemedicine Network .....................................................59
Operational Definition ...................................................................59
Case Selection Criteria …………………………………………..63
Selected Cases................................................................................63
iv
IV.
RESULTS ...............................................................................................65
Introduction ................................................................................................65
Mission Statement, Goals, Objectives .......................................................66
Academic Medical Systems ...........................................................66
Non-academic Medical Systems ....................................................71
Statewide Telemedicine Networks ................................................75
Insurer Based Programs .................................................................80
Comments ......................................................................................81
Background Questions ...............................................................................82
Evaluation Questions ...............................................................................111
V.
DISCUSSION ......................................................................................127
Introduction ..............................................................................................127
Research Question One ............................................................................127
Research Question Two ...........................................................................130
Research Question Three .........................................................................132
Research Question Four ...........................................................................133
Specific Organizational Initiatives ...........................................................135
Comments ................................................................................................141
Telemedicine Theory ...............................................................................142
Cybernetic Model.........................................................................142
Diffusion of Telemedicine ...........................................................144
Critical Mass ................................................................................146
Recommendations for Developing, Growing, and Sustaining a
Telehealth Network..................................................................................146
Recommendations for Future Study ........................................................148
BIBLIOGRAPHY ...........................................................................................149
APPENDIX ......................................................................................................161
v
LIST OF FIGURES
Figure
Page
1. Typology of Telemedicine Technology .............................................................10
2. Pombortsis‟ Typology of Medical Telecommunications Applications .............12
3. Typology of Telehealth ......................................................................................15
4. Growth of Telemedicine Literature, 1960-1999 ................................................20
5. Number of US Telemedicine Programs by Year, 1994-99 ................................27
6. Growth Rate of US Telemedicine Programs and Activity by Year, 1994-99 ...27
7. Physicians Per 100,000 Population ....................................................................29
8. Rural Poor in the United States..........................................................................30
9. Primary Care HPSAs (Health Professional Shortage Areas), 1996 ...................32
10. Cramp and Carson‟s Simplified Conceptual Healthcare Model ......................42
11. Cramp and Carson‟s Public Healthcare Digraph .............................................44
12. Roger‟s Diffusion of Innovation Stages ..........................................................46
13. University of Tennessee Telemedicine Network (2000), Geographic Model .60
14. Telemedicine Network, Clinical Model ...........................................................62
15. Arizona Telemedicine Program Sites ..............................................................67
16. ECU Telemedicine Sites ..................................................................................70
17. Eastern Montana Telemedicine Sites ...............................................................72
18. Marshfield Clinic Sites ....................................................................................74
19. KUCTT ITV Sites ............................................................................................76
20. Missouri Telehealth Network Sites ..................................................................79
vi
21. Timeline of Telemedicine Programs by Year They Began .............................84
22. Simplified Conceptual Telehealth Model ......................................................143
vii
LIST OF TABLES
Table
Page
1. Publication Patterns of Six Major Telemedicine Journals .................................21
2. Growth of Telemedicine Programs and Activities by Year ...............................23
3. Telemedicine Program by Number of Employees .............................................88
4. Telemedicine Program by General Applications ...............................................91
5. Telemedicine Program by Level of Service.......................................................93
6. Telemedicine Program by Setting ......................................................................94
7. Telemedicine Program by Technology ..............................................................99
8. Telemedicine Program by Equipment .............................................................100
9. Telemedicine Program by Activity ..................................................................102
10. Telemedicine Program by Funding Source....................................................103
viii
CHAPTER I
INTRODUCTION
"The future of medicine is telemedicine."
C. Everett Koop, M.D., Sc.D.1
“Telemedicine does not create new or different health care services.
It simply provides a revolutionary way to deliver existing medical or
health care services.”
Senator Bill Frist, M.D.2
Health care in the United States is in the midst of a paradigm shift, from a
traditional provider-centered, disease-oriented approach to a patient-centered, healthmanagement model. This paradigm shift is in part due to the use of interactive, audiovisual telecommunication technologies to deliver health care services. 3 This delivery
system is known as telemedicine.
C. Everett Koop quoted in “Telemedicine: A Promising Dream Faces Harsh Realities,” by H.L. Blatt.
Available at gsulaw.gsu.edu/lawand/papers/su98/telemed/.
1
Sen. Bill Frist, Chairman, Subcommittee on Science, Technology and Space, “Opening Statement,
Hearing on Telemedicine Technologies,” (September 15, 1999). Available at
http://www.senate.gov/~commerce/hearings/0915fri.pdf
2
John Haughton, “A Paradigm Shift in Healthcare: From Disease Management to Patient-Centered
Systems,” MD Computing (July/August 2000), 34-38. Available at
www.mdcomputing.com/issues/v17n4/haughton.htm.
3
Thomas, S. Kuhn, The Structure of Scientific Revolutions (Chicago: University of Chicago Press, 1962),
10.
1
According to the 1997 Telemedicine Report to Congress, "Telemedicine can mean
access to health care where little had been available before …. Telemedicine has the
potential to improve the delivery of health care in America by bringing a wider range of
services, such as radiology, mental health services, and dermatology to underserved
communities and individuals in both urban and rural areas." 4
Problem Statement
Although telemedicine has been touted as an answer to the disparity in access to
health care in the United States, use of telemedicine by health care professionals has been
uneven. Although telemedicine activity has been reported in forty-eight states, only nine
states accounted for 50 percent of the activity in 1998. Only fifty telemedicine programs
accounted for almost 60 percent of total telemedicine activity. 5
In order to understand why and how telemedicine systems may be implemented,
sustained and grown, it would be useful to examine the infrastructure of several different
types of benchmark telemedicine networks that have been identified and commonly
accepted as successful in developing and using telemedicine to improve access to health
care.
4
United States Department of Commerce and United States Department of Health and Human Services.
Telemedicine Report to Congress (January 31, 1997). Available at www.ntia.doc.gov/reports/telemed/.
5
Bill Grigsby and Nancy Brown, 1999 Report on U.S. Telemedicine Activity (Portland: Association of
Telehealth Service Providers, 2000), iv, 4.
2
Purpose of the Study
This dissertation focuses on telemedicine delivery systems, including allied
telehealth activities. It examines the infrastructure of telemedicine across and within
different types of organizations and, from this, develops recommendations for network
development, sustainability and growth.6 In addition, a survey instrument was developed
to determine organizing infrastructure on a nationwide basis.
Research Method
To understand the diversity of organizational settings in which telemedicine
networks are now situated, this research examines networks that are located in the
following organizations: academic medical centers; non-academic medical centers;
statewide telemedicine networks; and telemedicine networks located within a health
insurance company.
The case study method is used to determine the organizational structure and
location of the telemedicine network within the larger “parent” organization. The
original purpose of the networks is examined, as well as the history of their development
and factors that contributed to and detracted from network development. Such factors as
funding sources; health care provider and patient acceptance; technical factors; location
within the parent organization; availability or non-availability of reimbursement; and
other factors that were discovered through in-depth interviews with key informants
3
within the telemedicine network under study. Key informants were chosen based on their
length of stay within the network and by recommendations from personnel within the
network under study and from personnel in other networks.
Research Questions
The following research questions were used to guide the research (see Appendix
2: Survey Instrument):
1. What is the organizational structure of an academic institution/school of
medicine telemedicine network versus a non-academic institution/school of
medicine telemedicine network versus a statewide telemedicine network
versus an insurer-run telemedicine network? What is the hierarchical
structure, funding source(s), type and level of staffing?
2. What kinds of human resources are necessary, and what roles must they play?
What capabilities are necessary?
3. What are the organizational problems and barriers of building, maintaining,
and sustaining a telemedicine network?
4. What organizational structure is most conducive for success in a telemedicine
network? Success can be defined as sustainability, full use, increased access
In this study, the term “growth” refers to growth in the numbers and types of telemedicine or telehealth
encounters.
6
4
and diversity of services offered. The definition of success will be determined
by the key informants of a particular telemedicine network.
Limitations of the Study
A large area of telemedicine is military telemedicine, which the federal
government has funded and promoted as a way to improve access to primary care,
specialty consultations, and battlefield medicine with a limited number of military health
professionals. The study of the organization and use of telemedicine in the military is
beyond the scope of this study. This research will focus on civilian applications of
telemedicine in the United States.
Prison telemedicine services a unique population that is not excluded from this
study, but will be examined in the context of being part of a larger telemedicine network.
There has been some criticism of case study research, in that it relies heavily on
qualitative data such as interviews with key informants. This limitation may be overcome
by following research protocol and by triangulating, or cross-checking, data from key
informants with other published data and archival records. While this may assure
accuracy of the data presented, the completeness of the data is dependent upon the skills
and thoroughness of the researcher.
Note
5
At the time of this study, the terms “telemedicine” and “telehealth” are generally
accepted and are not hyphenated. Less familiar sub-disciplines, such as tele-dermatology
or tele-radiology are hyphenated for clarity and consistency.
6
CHAPTER II
REVIEW OF THE LITERATURE
A review of the research literature covers five main areas: background
information about telemedicine; the involvement of the federal government in the
development of telemedicine programs as a strategy to address medically underserved
populations; the adoption of technology by health care organizations and health care
providers, and telemedicine theory. Finally, case studies and surveys of telemedicine
networks are reviewed to demonstrate the research that has been done in this area and to
justify the need for continuing research.
Telemedicine
Definition
While there is not yet a definitive or universally accepted definition of
telemedicine, the word itself implies the use of telecommunications for medical purposes.
The word telemedicine derives from the words tele, Greek for “far off,” and the Latin
medicus or physician, so telemedicine may be defined literally as “medicine practiced
from a distance.”
Reid defines telemedicine as "the use of advanced telecommunications
technologies to exchange health information and provide health care services across
7
geographic, time, social, and cultural barriers" and insists it is not a new discipline within
medicine, but “a new way of doing the same old things.” 7
Telemedicine is defined by Perednia and Allen as “the use of telecommunications
technologies to provide medical information and services.” 8 However, they also note:
“Although this definition includes medical uses of the telephone, facsimile, and distance
education, telemedicine is increasingly being used as shorthand for remote electronic
clinical consultation.”9
Bauer and Ringel have called telemedicine the seventh revolution in healthcare in
the modern era. They propose the following timeline:
1. Anesthesia – 1840s
2. Scientific Disease Model and Public Health – 1860s-1880s
3. Radiology and Diagnostic Imaging – 1890s
4. Medical Education Reform – early 1900s
5. Antibiotics and Prevention – 1920s
6. Genetics and Pharmaceuticals – 1980s
7. Telemedicine and Telehealth – 1990s10
7
Jim Reid, A Telemedicine Primer: Understanding the Issues (Topeka KS: Innovative Medical
Communications, 1996), 10, 13.
Douglas A. Perednia and Ace Allen, “Telemedicine Technology and Clinical Applications,” Journal of
the American Medical Association (February 8, 1995), 483.
8
9
Perednia and Allen, 483.
10
Jeffrey Bauer and Marc Ringel, Telemedicine and the Reinvention of Healthcare (New York: McGrawHill, 1999), 59-74.
8
Typology
As in every new area of research, a descriptive typology is being developed to
organize and categorize the various aspects of telemedicine and telehealth. Some use the
two terms interchangeably, but the term “telemedicine” implies the use of
telecommunications for medical consultation, diagnostic or treatment purposes.
“Telehealth” implies the inclusion of preventive measures, patient education and/or
monitoring for the maintenance of health.
Technology Typology
Brown, of the Telemedicine Information Exchange, classifies telemedicine as a
sub-category of E-Health. It is “a general term encompassing health care delivery,
administration and information dissemination.”11 Telehealth implies the use of more
traditional telecommunications technology, such as video-phones while E-health implies
the use of computer technology. Telemedicine, in turn, may be divided into two types: (1)
store and forward for "transferring digital images from one location to another” and (2)
two-way interactive television used when "a consultation between the patient, primary
provider, and specialist is necessary.” 12
Nancy Brown, “Telemedicine Coming of Age,” Telemedicine Research Center (September 28, 1996).
Available at trc.telemed.org/telemedicine/primer.asp.
11
12
Brown. trc.telemed.org/telemedicine/primer.asp.
9
A third technical category, virtual or 3-D technology, is futuristic although some
work is being conducted in the area of robotic surgery (Figure 1).
TeleMedicine Technology
Store & Forward
Interactive/ 2-way
Virtual/3-D
Figure 1.
Typology of Telemedicine Technology
10
Pombortsis proposes a more complex two-dimensional typology of medical
telecommunications applications according to data volume and level of interactivity
(Figure 2).
User Typology
Brauer also categorizes telemedicine and tele-education as subsets of telehealth,
but from a user perspective. He defines telemedicine as, “patient-care-oriented clinical,
diagnostic and therapeutic activities” and tele-education as, “provider-oriented services,
such as access to information and linkages with other practitioners.”13
Applications Typology
The National Library of Medicine categorizes telemedicine into three basic areas:
aides to decision-making (remote expert systems or databases); remote sensing or teletransmission of patient data; and real-time interaction of patients and health care
providers.14 In a survey of telemedicine research, Taylor divides telemedicine services
similarly into three broad categories: 1) treatment services, 2) diagnostic or management
services, and 3) educational services.15
Gerhard W. Brauer, “Telehealth: The Delayed Revolution in Health Care,” Medical Progress Through
Technology (1992), 151-63.
13
14
Kristine M. Scannell, Douglas A. Perednia and Henry M. Kissman, Telemedicine: Past, Present, Future:
January 1966 through March 1995 (Washington, D.C.: National Library of Medicine, 1995). Available at
www.nlm.nih.gov/pubs/cbm/telembib.html.
Paul Taylor, “A Survey of Research in Telemedicine 2: Telemedicine Services,” Journal of Telemedicine
and Telecare (1998), 63-71.
15
11
Figure 2.
Pombortsis’ Typology of Medical Telecommunications Applications 16
Grigsby et al. classified clinical applications of telemedicine into nine categories
of general applications and processes:
1. Initial urgent evaluation and triage
2. Medical and surgical follow-ups
3. Primary care consultations
4. Specialty consultations and second opinions
5. Transmission of digital diagnostic images
Andreas S. Pombortsis, “Communication Technologies and Applications in a Medical Environment” in I.
Iakovidis, s. Maglavera, and a Trakatellis, eds., User Acceptance of Health Telematics Applications
(Washington, D.C.: IOS Press, 1998), 184.
16
12
6. Diagnostic work-ups for specific conditions
7. Monitoring of chronic diseases and conditions
8. Transmission of medical data
9. Public health and education.17
Comprehensive Typology
A comprehensive classification system is detailed by Reid who categorizes
telemedicine according to level of service, setting, health care discipline, technology,
equipment, data type, and activity:
1.
Level of service (tele-consultation, tele-care, tele-monitoring, telehealth)
2.
Settings/end-user locations (hospital, clinic, home, prison, workplace)
3.
Healthcare discipline (medical specialty, nursing, allied health)
4.
Technology system(s) (interactive video, store and forward)
5.
Equipment used (room systems, rollabouts, PCs, mobile, set-top boxes)
6.
Technology data (data, audio, graphics, video, virtual tele-presence)
7.
Activity (clinical, educational, administrative, business). 18
The telemedicine typology of Grigsby et al. maps to Reid‟s typology system in
two areas: level of service and healthcare discipline.
Reid 1. Level of service
Grigsby et al. 1. Initial urgent evaluation and triage
2. Medical and surgical follow-ups
17
Jim Grigsby, Robert E. Schlenker, Margaret M. Kaehny, Peter W. Shaughnessy, and Elliot J. Sandberg,
“Analytic Framework for Evaluation of Telemedicine,” Telemedicine Journal 1 (1995), 36-37.
Jim Reid, “Telemedicine Applications: Today and in the Future,” slide presentation (1998). Available at
www.telemedprimer.com/htb1198/tsld001.htm.
18
13
5. Transmission of digital diagnostic images
6. Diagnostic work-ups for specific conditions
7. Monitoring of chronic diseases and conditions
8. Transmission of medical data
Reid 3. Healthcare discipline
Grigsby et al. 3. Primary care consultations
4. Specialty consultations and second opinions
Proposed Typology Model
A typology model of telehealth and telemedicine (Figure 3) is proposed based on
types of general healthcare services offered by nurses and allied healthcare workers
(Tele-Monitoring, Tele-Nursing, Tele-Allied Care); primary care and specialty physicians
(TeleMedicine, Tele-Consultation, Tele-Diagnosis, Tele-Treatment); and healthcare
educators and administrators (Tele-Education for providers and/or patients, TeleAdministration, and Tele-Business related to healthcare).
14
TeleHealth
Tele-Monitoring
TeleMedicine
Tele-Education
Tele-Nursing
Tele-Consultation
Tele-Administration
Tele-Allied Care
Tele-Diagnosis
Tele-Business
Tele-Treatment
Figure 3.
Typology of Telehealth
Tele-monitoring, Tele-nursing
Tele-monitoring, tele-nursing, and tele-allied care have been shown to be
effective in improving and maintaining patients with chronic disease.
A pilot telemedicine project in Scott County, Tennessee, affiliated with Mountain
Peoples Clinic, monitored two groups of patients, a group of congestive heart failure
patients (CHF) and a group of diabetic patients. Telemedicine equipment installed in the
patients‟ homes included a television monitor, a telephone, a camera and ViaTV
15
converter equipment to provide real-time, audio-video home health consultations with the
telemedicine nurses using plain old telephone system (POTS) lines.
The CHF patients received tele-monitoring equipment: three-lead EKG, blood
pressure, pulse and blood oxygen saturation levels. Using store-and-forward technology,
results were sent to the Scott County Telemedicine Center each week over POTS lines. In
addition, standardized weight scales were given to each patient so the nurse could
monitor their weight.
Diabetic patients were given Accu-check blood glucose monitors to store-andforward their blood glucose levels via POTS lines.
Tele-monitoring of CHF patients reduced the number of acute heart failure
episodes and significantly reduced the number of hospitalizations. Tele-monitoring of
diabetic patients resulted in a 200 percent increase in those who have their blood sugar
under control.19
Clinical Telemedicine, Tele-Consultations
The University of Tennessee TeleHealth Network conducts specialty
consultations with patients in smaller hospitals and clinics in the East Tennessee region.
The patient, accompanied by a nurse at the spoke site, is located in a telemedicine
examination room equipped with a monitor and digital audio-visual equipment. A
Susan L. Dimmick, Samuel G. Burgiss, and Sherry Robbins, “Differences in Communication Mode in a
Home Telehealth Project for Diabetics.” Poster paper presented to the American Telemedicine Association,
Fort Lauderdale, FL (February 2001). Selected as a top scientific poster paper.
Samuel G. Burgiss and Susan L. Dimmick, "Telehealth in Home Health Care," In Telecommunications for
Nurses: Providing Successful Distance Education & Telehealth, 2nd Edition, M.L. Armstrong and S.
Frueh, eds. New York: Springer Publishing, 2002.
19
16
medical specialist, such as a dermatologist, at the UT Medical Center Telemedicine
Department can have an interactive encounter with the patient and attending nurse.
Dedicated high-bandwidth phone lines allow a clear, detailed view, and the
specialist, with the attending nurse‟s assistance, may zoom in for a closer view or may
order tests to be done at the local site. Medical records are easily faxed to the specialist
and doctor‟s orders and prescriptions faxed back to the patient.
Origins and Development
While the technology for two-way, interactive audio-video communication has
been in existence since the late 1950s, it was not until the 1990s that the use of
telemedicine to improve access to health care proliferated.
A 1959 article on store and forward tele-radiology documents the transmission of
tele-fluoroscopes over coaxial cable by Dr. Albert Jutras in Montreal beginning in 1957.20
Dr. Cecil Wittson of the Nebraska Psychiatric Institute co-authored a 1956 article on the
use of telemedicine for education21 and a 1961 article on the use of two-way television in
group therapy (tele-psychiatry).22
Albert Jutras, “Teleroentgen Diagnosis by Means of Videotape Recording,” American Journal of
Roentgenology 82 (1959), 1099-102.
20
21
Cecil Wittson and R. Dutton, “A New Tool in Psychiatric Education,” Mental Hospitals 7 (1956), 11-14.
Cecil Wittson, DC Affleck, and V Johnson, “Two-Way Television in Group Therapy,” Mental Hospitals
12 (November 1961), 22-3.
22
17
Bashshur cites Bird as the “first pioneer to develop a complete prototype
system.”23 The Tele-diagnosis system, first established in 1968, connected
Massachusetts General Hospital and Logan International Airport Medical Station with
interactive video as well as electronic transmission of electrocardiograms, blood
pressures and stethoscope sounds.
Telemedicine was advanced in the early 1960s when, NASA, the National
Aeronautics and Space Administration, first put men in space. Physiological
measurements of the astronauts were tele-metered from both the spacecraft and the space
suits during NASA space flights. 24
The development of satellite and digital technology to monitor the health status of
astronauts has fostered the development of terrestrial applications of telemedicine as well.
A pioneer telemedicine project, STARPAHC, or Space Technology Applied to
Rural Papago Advanced Health Care, was developed by NASA to deliver health care to
the Papago Indian Reservation in Arizona. The project, which ran from 1972 to1975, was
implemented and evaluated by the Papago people, the Indian Health Service, and the
Department of Health, Education, and Welfare. The goal was to provide health care to
the isolated and medically underserved Papago Reservation. A van, staffed by two native
paramedics, was equipped with a variety of medical instruments, including an
Rashid L. Bashshur, “On the Definition and Evaluation of Telemedicine,” Telemedicine Journal 1
(1995), 21.
23
National Aeronautics and Space Administration, “NASA Telemedicine History” (February 6, 1997).
Available at
http://web.archive.org/web/19970716104306/http://www.it.hq.nasa.gov/~kmorgan/telemed_blue/history/hi
story.html
24
18
electrocardiograph and x-ray machine. This mobile unit was linked to specialists at the
Public Health Service Hospital by a two-way microwave transmission.25
Although STARPAHC was successful in increasing access to health care to a
medically underserved population, the project was expensive, and like many of the early
telemedicine programs, it died from lack of funding and provider participation.
With the decreasing cost and increasing bandwidth of technologies in the latter
half of the 1990s came a renewed interest in telemedicine.
Research Literature
The growth and development of telemedicine as a field of study is reflected in the
research literature. Seventy percent of the more than 8,000 documents indexed in the
Telemedicine Information Exchange database (tie.telemed.org/) were published between
1995 and 1999 (Figure 4).26 The six major telemedicine journals identified by TIE began
publication since 1994 (Table 1).27
National Aeronautics and Space Administration, “NASA Telemedicine: Terrestrial Applications”
(November 22, 1996). Available at
http://web.archive.org/web/19970803095856/www.it.hq.nasa.gov/~kmorgan/telemed_blue/history/history_
apps.html
25
Teresa Welsh, “The Literature of Telemedicine: A Bibliometric Study,” Poster Presentation, The
Association of Library and Information Science Educators Conference, New Orleans, LA. (January 2002).
26
27
Ibid.
19
6000
5631
Citations in TIE Database
5000
4000
3000
2000
1301
1000
1
19
59
105
138
150
1960-64
1965-69
1970-74
1975-79
1980-84
1985-89
0
1990-94
1995-99
Publication Years
Figure 4.
Growth of Telemedicine Literature, 1960-1999
Number of Citations in TIE Database by Five-Year Increments
20
Table 1.
Publication Patterns of Six Major Telemedicine Journals
Journal by Number of Citations in TIE per Year, 1994-1999
Journal
‘94 ‘95
‘96
‘97
‘98
‘99 Total
24
50
61
82
69
293
59
J Telemed & Telecare
37
101
76
90
101
405
81
Telemedicine Journal
37
35
30
37
121
260
52
1
16
20
37
74
25
27
26
32
85
28
27
80
107
54
282
433
1,224
50
Telemedicine Today
7
Mean
Telemedlaw
IEEE IT BioMed
Telehealth
Citations in
TIE Database
7
98
187
210
A systematic review, in 1997 by Balas et al., of clinical trial reports on the
efficacy of distance medicine electronic technologies found favorable evidence that these
technologies could improve access to healthcare and support quality and continuity of
clinical healthcare.28
E. Balas, et al., “Electronic Communication with Patients: Evaluation of Distance Medicine
Technology,” Journal of the American Medical Association 278 (July 9, 1997), 152-59.
28
21
Current Trends, Uses, and Benefits
The number of telemedicine programs and telemedical encounters in the United
States is growing. In 1993, 10 programs performed 1,750 telemedical encounters, an
average of 175 per program. In 1999, 179 programs performed more than 70,000
telemedical encounters, an average of 608 telemedical encounters per program (Table
2).29
Peter Leitner, industry expert and creator of the Waterford Telemedicine Index,
reports that the telemedicine industry worldwide grew from $6.8 billion in 1997 to $13.8
billion in 1998. He cites “increasing consumerism, changing demographics, hardware
price deflation and the proliferation of the Internet” as its driving factors. He estimates
that telemedicine will represent 15 percent of all health care expenditures by 2010. 30
Table 2.
Growth of Telemedicine Programs and Activities by Year, 1993-199931
1993
1994
1995
1996
1997
1998
Number of Telemedicine
Programs
10
24
49
Number of Telemedicine
Encounters
1,750
2,110
6,138
29
86
132
1999
157
179
21,732 41,740 52,223
74,828
Grigsby and Brown, 4.
30
Deborah R. Dakins and Peter Leitner, The Telemedicine Industry Report 2000 (New York: Waterford,
Inc., 2000).
31
Grigsby and Brown, 4.
22
The reasons most cited for using telemedicine include increased access to health
care, increased quality of health care, and more efficient use of health care resources. 32
Telemedicine is used in a variety of ways. The telemedicine services with the
most use include: specialist consultations, chronic disease management, and
medical/surgical follow-ups.33 The top telemedicine specialty services offered by
providers in 1999 include, in order of frequency:
radiology
cardiology
emergency care
pathology
dermatology
psychiatry
home health
oncology.34
The greatest benefits and lowest costs of medical care are obtained by providing
the appropriate level of care at the appropriate time.35 A study of rural tele-dermatology
Susan L. Dimmick, Carole Mustaleski, Samuel G. Burgiss, and Teresa Welsh, “A Case Study of Benefits
and Potential Savings in Rural Home Telemedicine,” Home Healthcare Nurse 18 (February 2000), 126.
32
33
Grigsby and Brown, 18.
Deborah R. Dakins, “Increased Investment and Incremental Expansion Fuels Optimism,” Telehealth
Magazine (June 1999), 28-31.
34
35
Samuel Burgiss, “Telemedicine” Congressional Testimony, Congressional Record (September 15, 1999).
23
patients in the University of Tennessee Telehealth Network reports that fewer teleconsultations with a dermatologist were required for diagnosed skin conditions than for
the average number of treatments for the same conditions by a general care provider.
The average cost of primary care for skin disease was more than twice that of a
specialist‟s care using tele-dermatology ($294 versus $141).36
Two areas of telemedicine that have proven to be particularly cost-effective are
correctional telemedicine and tele-homecare. Correctional telemedicine, responsible for
about 30 percent of telemedicine activity, 37 can increase inmate access to medical
specialists while reducing costs.38 A study of tele-homecare in rural East Tennessee
reported a cost-savings of about $50 per visit for tele-care over a conventional in-home
nurses‟ visit.39 A similar tele-homecare study in California found a 60 percent savings in
time (an average of 18 minutes for a tele-visit versus 45 minutes for an in-person visit).
With telemedicine, a homecare nurse could “visit” 15 to 20 patients a day, as opposed to
an average in-person daily caseload of 5.2 patients.40
Samuel G. Burgiss et al., “Telemedicine for Dermatology Care in Rural Patients,” Telemedicine Journal
3 (1997), 230-31.
36
37
Grigsby and Brown, 5.
United States Department of Justice, “Telemedicine Can Reduce Correctional Health Care Costs: An
Evaluation of a Prison Telemedicine Network” (March 1999). Available at:
http://www.abtassoc.com/reports/telemedicine/ES-175040.pdf
38
39
Dimmick et al., 129.
24
In addition to reducing the costs of home care, tele-homecare has been shown to
reduce the number of office visits, the number of emergency room visits, the frequency
and duration of hospitalizations, and the number of long-term care placements.41
Rural telemedicine may have additional benefits to the local community
including:
improved health professional recruitment and retention
solidified referral relationships
enhanced image of the local health system
retention of health care revenues within the local community. 42
Barriers to Implementation and Use
Despite the benefits, successes and cost savings of telemedicine, the percentage of
telemedicine in overall health services is small. Association of Telemedicine Service
Providers president, Dr. Douglas Perednia, claims,
There are relatively few providers who know that telemedicine exists
and even fewer healthcare consumers. Our survey reported only 2,108
providers involved in telemedicine in 1997. That‟s a tiny number
compared to the hundreds of thousands of doctors in the United States
alone. Probably fewer than 1 percent of U.S. physicians actually deal with
telemedicine, and I would be willing to bet that fewer than 5 percent have
any working knowledge of it.43
Samuel Burgiss, “Telehealth: A Cutting Edge Medical Tool for the 21st Century,” Congressional
Testimony, Congressional Record (September 7, 2000).
41
Thomas S. Nesbitt, Jeffrey C. Ellis and Christina A. Kuenneth, “A Proposed Model for Telemdicine to
Supplement the Physician Workforce in the USA,” Journal of Telemedicne and Telecare 5 (1999), S2:21.
42
Douglas A Perednia, “The Telemedicine Market: An Interview with the ATSP‟s Doug Perednia, M.D,”
Telemedicine Today 7 (February 1999), 33.
43
25
The strength of the challenges facing telemedicine is indicated by the slowing
yearly growth rate of telemedicine programs and activity from 1994 to 1999, as opposed
to the number of programs per year (Figures 5 and 6).
Barriers perceived by health care providers to the implementation and use of
telemedicine include:
expensive long-distance communication charges
concerns about licensing when tele-consulting across state lines
an absence of standards for telemedicine practice
concerns about provider liability
technology systems incompatibility (hardware and software)
concerns about reimbursement for telemedicine patient encounters.44
Federal Government and Telemedicine
The federal government has been instrumental in funding telemedicine projects as
a way to address the disparity of access to health care services in the United States.
44
Nesbitt, Ellis and Kuenneth, S2:24.
26
Number of Telemed Programs
180
160
140
120
100
80
60
40
20
0
1994
1995
1996
1997
1998
1999
Figure 5.
Number of US Telemedicine Programs by Year, 1994-99
Telemed Programs
Tele-Consultations
Growth Rate Per Year
300%
250%
200%
150%
100%
50%
0%
1994
1995
1996
1997
1998
1999
Figure 6.
Growth Rate of US Telemedicine Programs and Activity by Year, 1994-99
Data source for Figures 5 and 6: 1999 Report of U.S. Telemedicine Activity45
45
Bill Grigsby and Nancy Brown, 1999 Report on U.S. Telemedicine Activity (Portland: Association of
Telehealth Service Providers, 2000).
27
In 1990, there were four federally funded telemedicine projects, in 1993, there
were ten, and in 1994, at least fifty federally funded programs were either active or in the
planning stages.46
Mal-distribution of Health Care
Despite massive funding efforts and multiple federal programs since the 1960s,
the geographic mal-distribution of access to health care is a persistent characteristic of the
American health care system.47 While the rural population has grown to more than fifty
million people (about 20 percent of the U.S. population), only about 9 percent of
physicians practice in rural areas (Figure 7).48
In addition to having less access to health care, the average rural resident has
greater health care needs than does his urban counterpart. Rural populations tend to be
poorer, older, less educated, and suffer more from both chronic diseases and acute
conditions than the general population.49 More than 14 percent of rural residents live in
poverty (Figure 8) and about 24 percent of rural children live in poverty (compared to 22
percent of urban). 50
46
Perednia and Allen, 5.
48
Council on Graduate Medical Education, 11.
Thomas A. Pearson and Carol Lewis, “Rural Epidemiology: Insights from a Rural Population
Laboratory.” American Journal of Epidemiology 148 (1998), 949-957.
49
Economic Research Service, U.S. Department of Agriculture, “Rural Income, Poverty, and Welfare”
(December 2000). Available at www.ers.usda.gov/briefing/IncomePovertyWelfare/.
50
28
350
304
300
235
250
200
168
150
123
88
100
76
123
70
53
50
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ro
00
)
M
rg
e
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al
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0
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Figure 7.
Physicians Per 100,000 Population
Data source: AMA from BHPr‟s ARF data, 1997 51
51
Council on Graduate Medical Education, Health Resources and Services Administration, Public Health
Service, U.S. Department of Health and Human Services, “Tenth Report: Physician Distribution and Health
Care Challenges in Rural and Inner-City Areas” (February 1998), xiii.
29
Figure 8.
Rural Poor in the United States52
Economic Research Service, U.S. Department of Agriculture, “Rural Income, Poverty, and Welfare:
Maps and Images Gallery” (November 2000). Available at
www.ers.usda.gov/Briefing/rural/Gallery/whpoor97.htm.
52
30
Pearson and Lewis note that rurality and low socio-economic status have been
shown to be risk factors for acute conditions as well as for chronic illnesses, such as
diabetes and coronary disease. Such disease is due to "detrimental trends in health
behaviors, a lack of effective health promotion messages and services, a crisis in access
to rural primary health care, and limitations in rural emergency medical systems.” 53 In
addition, “rural communities appear to be late adopters of positive health behaviors." 54
In 1970, to address the problem of health care mal-distribution, legislation was
passed to form the National Health Service Corps (NHSC, www.bphc.hrsa.gov/nhsc/)
and Critical Health Manpower Shortage Areas (CHMSA) to identify areas with fewer
than one physician for every 4,000 residents. CHMSA evolved into HPSA, Health
Professional Shortage Areas (Figure 9). In 1978 the designation requirement for HPSA
was fewer than one primary care physician to 3,500 residents, and in areas with unusually
high service needs, a ratio of 1 to 3,000.55
Federal Telemedicine Projects
Various agencies and departments of the federal government have funded
telemedicine as a way to bring health care services to medically underserved populations.
53
Pearson and Lewis, 956.
54
Ibid., 956.
55
Council on Graduate Medical Education, 2.
31
Figure 9.
Primary Care HPSAs (Health Professional Shortage Areas), 199656
56
North Carolina Rural Health and Research and Policy Analysis Center, Cecil G. Sheps Center for Health
Services Research, University of North Carolina at Chapel Hill, “Primary Care Health Professional
Shortage Areas (HPSAs), 1996.” Available at
www.shepscenter.unc.edu/research_programs/Rural_Program/maps/hpsa96n.html.
32
In 1998, the Health Resources and Services Administration established OAT, the Office
for the Advancement of Telehealth, for the purpose of supporting “telecommunications
for technical assistance, training, and knowledge exchange among grantees, clinicians
and other health care professionals, especially those providing services to low-income,
medically underserved or isolated Americans.” 57
Other federal departments and agencies that support telemedicine initiatives
include:
National Aeronautics and Space Administration
Department of Agriculture
o Rural Utilities Service
Department of Commerce
o Technology Opportunities Program
o Department of Defense, National Telecommunications Information
Administration
Department of Health and Human Services
o Office of Rural Health Policy
o Health Care Financing Administration
o National Institutes of Health
o National Institute of Mental Health
o National Institute on Disability and Rehabilitation Research
o National Library of Medicine
o Agency for Health Care Policy and Research
57
Health Resources and Services Administration, United States Department of Health and Human
Services, “HRSA Focuses Agency Resources on Telehealth,” HRSA News (May 22, 1998). Available at
http://newsroom.hrsa.gov/releases/oat.htm
33
Federal funding for telemedicine, over $100 million each year since 1995, 58
supports an array of telemedicine projects. The 1999 Report on U.S. Telemedicine
Activity lists four types of federal support for telemedicine:
1. Direct funding of federal programs, such as the Veterans‟ Administration,
Department of Defense, and Federal Bureau of Prisons;
2. Grants and awards for telemedicine projects by the Office for the
Advancement of Telehealth, Rural Utilities Service, National Library of
Medicine, and National Telecommunications Information Administration;
3. Awards and contracts for applied research, such as Health Care Financing
Administration studies, National Institute of Mental Health grants;
4. Funding of specific initiatives, such as the Universal Services
Adoption of Telemedicine Technology
An analysis of the recent research literature on the effect of telemedicine on
doctor-patient communication identified thirty-eight studies: six surveys of healthcare
providers and community attitudes, twenty-one post telemedicine encounter surveys, and
eleven qualitative encounter behavioral studies.59
Abstracted research findings were coded positively or negatively into twentythree categories: communication efficacy; patient-provider relations, rapport
development; patient and provider question-asking; patient and provider understanding;
58
Perednia and Allen, 483; Nesbitt, Ellis and Kuenneth, S2:21; Grigsby and Brown, 11,13.
Edward A. Miller, “Telemedicine and Doctor-Patient Communication: An Analytical Survey of the
Literature,” Journal of Telemedicine and Telecare 7 (2001), 1-17.
59
34
patient and provider explanation; patient and provider comfort; embarrassment, anxiety,
audio and video quality, non-verbal behavior, lack of touch, self-viewing on screen,
multiple providers, patient involvement, privacy, encounter length, and miscellaneous
effect. The findings were 80 percent favorable to telemedicine in general, and
predominately favorable in all but two of the twenty-three categories, non-verbal
behavior and lack of touch.60
Patient Acceptance
A review of 32 studies of clinical patients‟ satisfaction with telemedical
encounters reports that patients generally are satisfied with telemedicine as a health
delivery system.61
A recent study of rural East Tennessee tele-homecare patients reported the results
of patient surveys and interviews that indicate a high degree of patient acceptance. More
than 80 percent rated the tele-homecare visit to be comfortable. More than 90 percent of
patients believed the quality of the tele-homecare visit to be as good as or better than a
traditional nurses‟ visit.62 In-depth interviews of nine patients and caregivers identified
perceptions of perceived benefits and disadvantages of tele-homecare delivered through
60
Ibid., 12-15.
Frances Mair and Pamela Whitten, “Systematic Review of Studies of Patient Satisfaction with
Telemedicine,” British Medical Journal 320 (June 3, 2000), 1517-20.
61
Dena S. Puskin, et al., “Patient and Provider Acceptance of Telemedicine,” New Medicine (Philadelphia:
Current Science, Inc., 1997), 55-59.
62
Dimmick et al., 131.
35
interactive audio-video (video camera, video monitor, speaker-phone, and electronic
interface to standard telephone line):
o The telemedicine equipment was easy for them to use
o Increased, faster access to “just in time” healthcare advice
o Increased sense of security and reduced anxiety with medical help a
videophone call away
o Reduced pain exacerbated by travel to the doctor or clinic
o Transportation time and cost savings
o More convenient than an in-home visit
o Didn‟t have to drive on dangerous rural roads, especially at night or
during bad weather
o Reduced confusion over medication, diet, and other instructions
o Increased personal attention from medical staff
o Added value of visualization of a problem, such as a wound
o Increased sense of privacy
o Increased sense of being in control.63
Some of the disadvantages of the tele-homecare visit include occasional
technical problems with the equipment or phone lines. Two of the nine patients
interviewed reported missing their lung sounds or blood pressure taken by an in-home
nurse.
63
Ibid., 130.
36
Provider Acceptance
While the level of patient acceptance of telemedicine is generally high, provider
acceptance is somewhat lower. Grigsby asserts that physician reluctance to adopt
telemedicine is attitudinal and may reflect such issues as political philosophy, lack of
behavioral and financial incentives, and the perception of telemedicine as a threat. 64
An investigation of physician acceptance of telemedicine found that telemedicine
adopters had much greater interest in using the technology routinely than non-adopters.
Survey data support the Theory of Planned Behavior, which states that a behavior can be
explained in large degree by the intention to do that behavior. 65
A survey of Hong Kong physicians found a difference by specialty in intention to
use telemedicine. Clinicians with multiple specialties expressed a significantly stronger
intention to use telemedicine than single-specialty clinicians. Of the single-specialty
clinicians, neurosurgeons and emergency physicians expressed the strongest intention to
use telemedicine in the future.66
In the same study, researchers also found variation in the degree of actual
telemedicine technology adoption by physician specialty. Radiologists, pathologists and
surgeons are the most frequent adopters and family practitioners the least.67
64
Jim Grigsby, “Current Status of Domestic Telemedicine,” Journal of Medical Systems 19 (1995), 25.
Paul Jen-Hwa Hu and Patrick Yam-Keung Chau, “Physician Acceptance of Telemedicine Technology:
An Empirical Investigation,” Topics in Health Information Management 19 (1999), 32.
65
Olivia R. Liu Sheng, et al., “A survey of Physicians‟ Acceptance of Telemedicine,” Journal of
Telemedicine and Telecare 4 (1998), 102.
66
67
Hu and Chau, 30.
37
A study of primary care physicians in rural Kansas reported that the only practice
characteristic significantly related to the use of telemedicine was referral pattern. While
three of seventeen non-users of telemedicine occasionally referred patients to specialists
at the University of Kansas Medical Center, three of nine users of telemedicine routinely
referred patients to UKMC specialists (17.6% versus 33.3%). The authors of this study
suggest a strong outreach program that promotes referrals to the hub site could increase
the use of telemedicine.68
The Internet and E-Mail
The acceptance and use of the Internet and e-mail for medical consultations
reflect the acceptance patterns of telemedicine in general, that is acceptance by the
majority of healthcare consumers, and less acceptance by healthcare providers.
A survey of oncology patients by Katzen and Dicker found that 72 percent felt
comfortable corresponding with their doctor via e-mail for minor health problems in nonurgent situations. Even those patients not currently using e-mail responded favorably to
the idea of corresponding with their doctor or his staff using e-mail.69
A survey of 209 unsolicited e-mails from dermatology patients to healthcare
providers found that 81 percent of patients seeking tele-advice suffered from a chronic
Pamela Whitten and E.A. Franken, “Telemedicine for Patient Consultation: Factors Affecting Use by
Rural Primary-Care Physicians in Kansas,” Journal of Telemedicine and Telecare 1(1995), 142, 143.
68
C.S. Katzen and A.P. Dicker, “A Survey to Evaluate Patients‟ Perspective Concerning E-mail in an
Oncology Practice,” International Journal of Radiation Oncology* Biology* Physics 51 (November 2001),
101.
69
38
disease. According to the authors‟ evaluation, only 28 percent were suitable questions to
be answered by healthcare professionals via e-mail. About 40 percent could have been
answered by a librarian. The authors concluded that while tele-advice via e-mail may be
overused by chronically ill and frustrated patients, e-mail communication could substitute
for an office visit in some cases.70
A Harris Interactive survey reports that about 90 percent of respondents would
like to contact their physician online and about 40 percent would be willing to pay for
such a service. Seventy-seven percent would like to ask medical questions, 71 percent to
schedule appointments, 71 percent to request prescription renewals, and 70 percent to
receive medical test results.71
A Harris Interactive survey of 834 physicians found that about 55 percent use email to communicate with professional colleagues, 34 percent e-mail support staff, but
only 13 percent use e-mail to communicate with patients.72
According to a survey by Fulcrum Analytics and Deloitte Research, physician
concerns about e-mail include reimbursement, privacy of patient information, and
potential malpractice liability.73
Gunther Eysenbach and Thomas L. Diepgen, “Patients Looking for Information on the Internet and
Seeking Teleadvice: Motivation, Expectations, and Misconceptions as Expressed in E-mails Sent to
Physicians,” Archives of Dermatology 135 (February 1999), 151-156.
70
Humphrey Taylor and Robert Leitman, eds., “Patient/Physician Online Communication: Many Patients
Want It, Would Pay For It, and It Would Influence Their Choice of Doctors and Health Plans,” Harris
Interactive Health Care News 2 (April 10, 2002). Available at:
http://www.harrisinteractive.com/news/newsletters/healthnews/HI_HealthCareNews2002Vol2_Iss08.pdf
71
Humphrey Taylor and Robert Leitman, eds., “New Data Show Internet, Web Site and E-mail Usage by
Physicians All Increasing,” Harris Interactive Health Care News 1 (February 26, 2001). Available at:
http://www.harrisinteractive.com/news/newsletters/healthnews/HI_HealthCareNews2001Vol1_iss8.pdf
72
39
Spielberg suggests that physicians should be aware of liability issues and should
preserve patient privacy and confidentiality by encrypting e-mail messages.74
Five agendas to shape patient-physician electronic communications have been
identified by Mandi et al.:
1. Definition of appropriate use
2. Security and confidentiality
3. Effective interfaces with user guidance
4. Proactive assessment of medical liability
5. Widespread, multicultural access.75
The American Medical Informatics Association (AMIA) has published a
white paper, “Guidelines for the Clinical Use of Electronic Mail with Patients.”
Guidelines include:
Establish turnaround time
Do not use e-mail for urgent matters
Inform patient that e-mail message will be part of medical record
Fulcrum Analytics and Deloitte Research, “Taking Technology‟s Temperature: Physicians Still Cool
Toward E-mail.” Available at http://www.fulcrumanalytics.com/news/releases/2002/01-29-fultakingthepulse.html
73
Alissa R. Spielberg, “On Call and Online: Sociohistorical, Legal, and Ethical Implications of E-mail for
the Patient-Physician Relationship, Journal of the American Medical Association 280 (October 21, 1998),
1353-1359.
74
Kenneth D. Mandi, Isaac S. Kohand, and Allan M. Brandt, “Electronic Patient-Physician
Communication: Problems and Promise,” Annals of Internal Medicine 15 (September 1998), 495-500.
75
40
Establish types of e-mail transactions permitted, such as prescription
refill, scheduling appointments, etc.
Instruct patients to put transaction category in e-mail subject line
Instruct patients to put name and patient ID number in message
Send auto-reply confirming receipt of patient message
Reply to inform patient of completion of request
Instruct patients to use auto-reply confirming receipt of provider
message
Maintain patient e-mailing list, but use blind copy feature to send
batch e-mails
Avoid negative emotions such as anger, sarcasm, criticism toward
patient or third party
Place print copy of e-correspondence in patient chart.76
Telemedicine Theory
Cybernetic Model
A simplified cybernetic healthcare model has been proposed by Cramp and
Carson as an effort toward quantifying healthcare and its effectiveness and maximizing
the value of telecare (Figure 10). The three main components of the model are healthcare
Beverley Kane and Daniel Z. Sands, “Guidelines for the Clinical Use of Electronic Mail with Patients,”
Journal of the American Medical Informatics Association 5 (Jan/Feb 1998), 104-111. Available at:
http://www.amia.org/pubs/other/email_guidelines.html
76
41
management (decision-makers), healthcare service provision, and the target population,
with information systems supporting management and providing a feedback loop.77
This model is useful in that it visualizes the role of technology in the support and
delivery of healthcare. The feedback loop also hints at changes in clinical research that
telemedicine could provide.
Figure 10.
Cramp and Carson’s Simplified Conceptual Healthcare Model 78
Derek G. Cramp and Ewart R. Carson, “A Model-Based Framework for Public Health A Vehicle for
Maximising the Value of Telecare?” S Laxminarayan, ed., Proceedings of the 3rd IEEE EMBS
International Conference on Information Technology Applications in Biomedicine (ITAB 2000),
Piscataway, NJ: IEEE, 2000, 272-277.
77
42
According to Bauer and Ringel, telemedicine can not only facilitate research, it
“will cause radical changes in the scientific definition of what „works‟ in medicine.”79
They foresee that research is likely to be changed by telemedicine in several
ways. The creation of networked databases encompassing an entire population of
comparable patients will reduce or eliminate the need for random sampling and statistical
analysis, and may drastically reduce the time and costs it currently requires to analyze
data and translate the findings into practice. 80
They also foresee an overall improvement in quality of research data since
“standardized data collection methods can be built into the computerized interfaces
between clinicians and patients”81 This type of electronic data collection has the
78
Crook and Carson, 275.
79
Bauer and Ringel, 94-97.
80
Ibid., 94-95.
81
Ibid., 95.
43
potential to eliminate biases, embed research protocols, and reinforce experimental
controls.82
Cramp and Carson also propose a more complex cybernetic digraph of public
healthcare that includes more detail of the factors influencing healthcare. More details
about the factors affecting healthcare are included, as well as causal connectivity and
direction of change (Figure 11).
Figure 11.
Cramp and Carson’s Public Healthcare Digraph 83
82
Ibid., 96.
44
The upper portion of the digraph “shows the population needs driven loops giving
rise to changes in service organization and provision, highlighting the relationships with
health service management performance, degree of accessibility to the services offered,
and hence service output and service outcome. This in turn impacts upon the health
outcome of the treated population, with improvement at this juncture leading to reduced
health problems ….”84
The lower portion of the model details population profile factors as a “driver and
determinant” of healthcare needs.85
Diffusion of Innovations
A prototype for the Diffusion of Innovations Model can be found in The Laws of
Imitation, written by French sociologist Gabriel Tarde in 1890, and first translated into
English in 1903. He noted the influential diffusion concept of opinion leadership and
observed the distinctive S-curve pattern of innovation adoption.86
83
Ibid., 275.
84
Ibid., 274.
85
Ibid., 274.
Paul Marsden, “Forefathers of Memetics: Gabriel Tarde and the Laws of Imitation,” Journal of Memetics
- Evolutionary Models of Information Transmission 4 (2000). Available at:
http://www.cpm.mmu.ac.uk/jom-emit/2000/vol4/marsden_p.html.
86
45
Everett Rogers, the name most associated with diffusion of innovations research,
defines diffusion as “the process by which an innovation is communicated through certain
channels over time among the members of a social system.87
Rogers developed a five-stage model that could be used in both an individual and
an organizational research level (Figure 12). His model of diffusion consists of
knowledge, or awareness of the innovation; persuasion, in which an opinion is formed
about the innovation; decision to adopt the innovation or not; implementation, if so
decided; and confirmation of the innovation.88
According to a more detailed Diffusion of Innovations Model (Appendix 3), prior
conditions that may affect the model include previous practice, felt needs and/or
problems, innovativeness, and social system norms.89
Knowledge
Persuasion
Decision
Implementation
Confirmation
Figure 12.
Roger’s Diffusion of Innovation Stages90
87
Everett Rogers, Diffusion of Innovations, Fourth edition (New York: The Free Press, 1995), 5.
88
Ibid., 10-11.
89
Ibid., 165.
90
Ibid., 10-11.
46
Characteristics of the decision-making unit that may influence knowledge include
socio-economic characteristics, personality variables, and communication behavior.91
Rogers enumerated some perceived characteristics of innovations that may
influence persuasion and may help to explain different rates of adoption:
1. Perceived relative advantage
2. Compatibility with values and needs of adopters
3. Perceived complexity of use
4. Trialability
5. Observability, visibility.92
Elements in the more complex diffusion model (Appendix 3) are connected by
communication channels that provide interactivity and a feedback loop similar to the
cybernetic model (see Figure 10).
At the individual level, Rogers calls those within the organization who have the
ability to influence others opinion leaders. Opinion leaders usually are social models and
are more cosmopolitan, more innovative, of higher social status and exposed to more
external communication than their coworkers.93
A related factor that may influence adoption of innovation is membership in
professional associations. The role of professional associations in diffusion was examined
91
Ibid., 165.
92
Ibid., 14-16, 165.
93
Ibid., 28.
47
by Swan and Newell. A survey of professional association members indicated
perceptions that the association was an important network for learning about new
research and development and in imparting knowledge important for the diffusion of new
technology. Predictors of diffusion include involvement in the association‟s professional
development activities, their firm‟s size, and degree of internal-communication within
their firms.94
In addition, rate of adoption may be influenced by organizational structure, such
as what Rogers calls “system effects, the influences of the structure and/or composition of
a system on the behavior of the member of the system,” 95 that is, whether the
organizational culture tends to be conducive to innovation, early adopters, early majority,
late majority or laggards 96
Rogers claims that, generally, “innovations that are perceived by receivers as
having greater relative advantage, compatibility, trialability, observability, and less
complexity will be adopted more rapidly than other innovations” and “are the most
important characteristics of innovations in explaining rate of adoption.”97
Diffusion of Innovations in Health Care Organizations
Jacky A. Swan and Sue Newell, “The Role of Professional Associations in Technology Diffusion,”
Organization Studies 16 (Winter 1995), 847-875.
94
95
Rogers, 25.
96
Ibid., 22.
48
A longitudinal study (over ten years) of more than four hundred California
hospitals found a strong relationship between inter-organizational links and innovation
adoption. Research methods included interviews with hospital and network executives,
mailed surveys, publications and industry reports and data. The authors, Goes and Park,
concluded, “hospitals that linked into multi-hospital systems, regularly exchanged
resources with related hospitals, and aggressively built institutional affiliations were more
likely to adopt innovative services and technologies.” 98
A study of the diffusion of telemedicine in North Carolina hospitals suggests three
characteristics of hospitals that adopt telemedicine:
1. They are larger, metropolitan hospitals
2. They are part of integrated delivery networks (IDNs)
3. They are not-for-profit organizations99
An examination of the adoption of MRI technology (magnetic resonance imaging)
in California, Oregon, and Washington hospitals focused on the relative roles of decisionmakers and environmental turbulence on technology adoption rates. The survey, targeting
administrative officers, found that physician and executive officer advocacy was strongly
97
Ibid., 16.
James B. Goes and Seung Ho Park, “Interorganizational Links and Innovation: The Case of Hospital
Services,” Academy of Management Journal 4 (June 1997), 684-87.
98
Sherry Emery, “The Diffusion of Telemedicine in the Southeastern United States: A Rural-Urban
Perspective,” Cecil G. Sheps Center for Health Service Research, University of North Carolina at Chapel
Hill,Chapel Hill, NC (June 1996).
99
49
related to early adoption of MRI technology in less turbulent hospital environments
(Oregon and Washington), but not in California. In the more volatile California hospitals,
hospital executives viewed the acquisition of new technology as a way of controlling
environmental turbulence.100
Critical Mass Theory
Markus expanded upon the Diffusion of Innovations Theory and the Critical Mass
Theory to develop a “critical mass explanation for the diffusion of interactive media, such
as telephone, paper mail systems, electronic mail, voice messaging, or computer
conferencing within communities”.101
Oliver et al. defined critical mass (a term borrowed from physics meaning the
amount of radioactive material required to produce a nuclear reaction) as a “small
segment of the population that chooses to make big contributions to the collective action,
while the majority do little or nothing.”102
In her studies of interactive media, Marcus describes an “accelerating production
function” in that the greater the number of users of an interactive technology, the more
Leonard H. Friedman and James B. Goes, “The Timing of Medical Technology Acquisition: Strategic
Decision Making in Turbulent Environments,” Journal of Healthcare Management 45 (September 2000),
317-331.
100
M. Lynne Markus, “Toward a Critical Mass Theory of Interactive Media: Universal Access,
Interdependence, and Diffusion,” Communication Research 14 (1987), 491.
101
Pamela Oliver, Gerald Marwell, and Ruy Teixeira, “A Theory of the Critical Mass. I. Interdependence,
Group Heterogeneity, and the Production of Collective Action,” American Journal of Sociology 91
(November 1985), 522-556.
102
50
value it has to the larger group. Widespread use leads to a maximum value of universal
access.103
Marcus replaces the Diffusion of Innovation‟s assumption of sequential
interdependence, in which later adopters are influenced by early adopters, with
Thompson‟s concept of reciprocal interdependence, “in which early adopters are
influenced by later ones or non-adopters as well as vice versa.”104
Early adopters of new interactive media experience relatively low benefits and
higher costs, but if use of a new medium becomes more widespread, costs drop, benefits
increase, and adoption within the general population is accelerated. “But if early users
are not reinforced by reciprocity from communication partners, they are very likely to
discontinue using the medium.”105
Case Studies, Surveys of Telemedicine Networks
A case study of a hospital in West Texas investigated the adoption of
telemedicine as an attempt by one rural hospital to remain viable and competitive within
the local community. The research method used was the examination of local media
103
Markus, 491.
104
J.D. Thompson. Organizations in Action (New York: McGraw-Hill, 1967) quoted by Marcus, 494.
R.E. Rice, “Communication Networking in Computer-Conferencing Systems: A Longitudinal Study of
Group Roles and System Structure,” M. Burgoon, ed., Communication Yearbook 6 (Newbury Park, CA:
Sage, 1982), 925-944. Quoted by Marcus, 495.
105
51
coverage of Texas Tech Health Sciences Center and its participation in the MEDNET
telemedicine project.106
Media reports were collected in three different time periods: 1980-87, the preMEDNET years; 1988-92, the MEDNET years; and 1993-97, the Healthnet years.
Findings of the study include:
Telemedicine technology was successful in providing educational and
medical support to the hospital staff
university and area public school.
underserved communities
The telemedicine network forged new links between the hospital, the local
Telemedicine links to rural clinics provided healthcare access to
The ability of telemedicine to increase the viability of the hospital,
however, was limited by a history of hospital financial problems and
conflicts that undermined community trust.107
A review of cast studies in tele-psychiatry concluded that even low-cost POTS
(plain old telephone system) video-phone consultations created a valuable connection
between specialists in academic centers and patients with a local healthcare provider
(doctor, nurse-practitioner or nurse) in rural areas. The principle value of the visual
Dianne Sykes and William Alex McIntosh, “Telemedicine, Hospital Viability, and Community
Embeddedness: A Case Study,” Journal of Healthcare Management 44 (Jan/Feb 1999), 59-71.
106
107
Ibid., 69-71.
52
element seems to be in creating a social presence, or tele-presence, with visual,
interpersonal cues, such as eye contact, nods, facial expressions, and body language. 108
A case study of the University of Kansas Telemedicine Program found that
organizational communication and structure may be critical to the successful adoption of
telemedicine technology. Recommendations that were adopted as a result of this study
include: a definition of employee roles and responsibilities, simplification of consultation
scheduling, clarification of leadership and decision-making, and clarification of
telemedicine terminology. 109
An investigation of whether and how telemedicine affects hospital costs was
based on surveys and interviews with hospital administrators in North Carolina, South
Carolina, and Georgia. Objectives of the research included: the identification of hospital
characteristics that are related to adopting telemedicine technology and the identification
of derived benefits from their adoption of telemedicine.110
Quantitative survey research data indicate that several factors independently
increase the odds of the adoption of telemedicine by hospitals: not-for-profit status, a
multi-hospital and/or network affiliation, and size (large number of hospital beds).111
Peter Cukor et al., “Use of Videophones and Low-Cost Standard Telephone Lines to Provide a Social
Presence in Telepsychiatry,” Telemedicine Journal 4 (1998), 313.
108
Pamela S. Whitten and Ace Allen, “Analysis of Telemedicine from an Organizational Perspective,”
Telemedicine Journal 1 (1995), 203-213.
109
110
Sherry Emery, Telemedicine in Hospitals: Issues in Implementation, Health Care Policy in the United
States, ed. John G. Bruhn (New York: Garland Publishing, 1998), 116.
111
Ibid., 116.
53
Qualitative survey and interview research data suggest that hospital administrators
adopt telemedicine as a competitive strategy and as a managed care strategy. 112
112
Ibid., 117.
54
CHAPTER III
METHODOLOGY
Case Study
Case study is a methodology that involves collecting evidence from multiple
sources. Yin notes that case studies should use a broad variety of techniques - surveys,
archive analyses, documentary searches, field observations, even quantitative data, “In
fact, the more all of these techniques are used in the same study, the stronger the case
study evidence will be.”113
Case study methodology is considered most appropriate when “a „how‟ or „why‟
question is being asked about a contemporary set of events over which the investigator
has little or no control.”114
The specific research methods used in these case studies include in-depth
interviews with key informants, coding interview transcripts with NUD*IST qualitative
software, triangulation of interview data with published reports and archival data, and
qualitative data analysis.
Research Design
Robert K. Yin, “Enhancing the Quality of Case Studies in Health Services Research,” Health Services
Research 34 (December 1999), 1214.
113
114
Robert K. Yin, Case Study Research: Design and Methods. Fourth edition. (Thousand Oaks: Sage
Publications, 1994), 9.
55
The quality of research design is based on such concepts as trustworthiness,
credibility, confirmability, and data dependability. 115 In case study research, these
concepts are addressed by specific tactics to assure construct validity and reliability. 116
Construct validity is defined by Yin as, “establishing correct operational measures
for the concepts being studied.”117 In this multiple case study, construct validity was
assured by triangulating, or cross-checking, with multiple sources of evidence and by
having the key informants review a draft analysis of their interview. No major changes
were necessary, but minor changes and additions for clarification were suggested by the
key informants and incorporated into the analysis. To assure accuracy, all of the data
were cross-checked with other sources including official Web sites, research publications,
and federal grant progress reports from the Office for the Advancement of Telehealth
obtained through a Freedom of Information Act request.
Reliability is defined by Yin as, “demonstrating that the operations of a study,
such as the data collections procedures, can be repeated, with the same results.”118
Reliability was assured in this multiple case study by pilot case study research, by
following case study protocol and by developing a case study database.
115
U.S General Accounting Office, Program Evaluation and Methodology Division, Case Study
Evaluations. (Washington, D.C: Government Printing Office, 1990).
116
Yin, 1994, 33
117
Ibid., 33.
118
Yin, 1994, 33.
56
Pilot case study research was conducted at the University of Tennessee
Telemedicine Network (recently renamed the University of Tennessee Telehealth
Network). Some of the research data contributed to the publication, “A Case Study of
Benefits and Potential Savings in Rural Home Telemedicine.”119 Interviews and surveys
conducted in the pilot case study research were instrumental in the development and
refinement of the survey instrument used in this study.
According to Yin, case study protocol should include:
An overview of the project, its purpose, objectives, case study issues and a literature
review of relevant readings
Field procedures and sources of information
Case study questions, including specific survey instrument, if applicable
A guide, or outline, for the case study report.120
Case study protocol outlined by Yin was used as a model and followed during the
course of this research study. A project database was developed using multiple formats.
Separate electronic and print folders for each of the eight cases studied contain
documents related to that particular case study, including interview transcripts, research
publications, and correspondence with key informants. A NUD*IST qualitative
119
Dimmick, et al., February 2000.
120
Yin, 1994, 64, 65.
57
software project database contains all of the interview transcripts, the coding protocol,
and the coding for each node within the protocol.
A survey instrument was developed to guide the key informant interviews and to
use as a prototype for future studies (Appendix 2). Key informants from each case study
were furnished the survey instrument in advance to prepare them for the interview and to
allow them to assemble the requested documents, such as an organizational chart.
Written and oral permissions were obtained from the key informants to audio-tape
the interviews. Interviews were conducted in person, by telephone, or, by videophone
using telemedicine technology at the University of Tennessee Telehealth Network.
Interviews were transcribed verbatim, and the ninety-seven transcribed pages
were coded using the qualitative analysis software, NUD*IST N4. The data was
triangulated by cross-checking with other authoritative sources including:
Case study‟s Web sites and marketing publications
Federal OAT grant progress reports
Telemedicine Information Exchange online database
Research publications.
Results from each telemedicine program were compiled, analyzed and compared
for similarities and differences among different types of telemedicine networks in:
1. Organizational structure, type and level of staffing
2. Kinds of human resources, their roles and necessary capabilities
58
3. Organizational problems and barriers of building, maintaining, and
sustaining a telemedicine network
4. Organizational structure most conductive for a successful telemedicine
network.
Unit of Study - Telemedicine Network
Operational Definition
Operationally defining the case or cases to be examined is perhaps the most
difficult but important step in case study research. Without a clear and precise definition,
there is danger that the findings may not be applicable to the original case, and in
multiple case studies, findings may not be comparable.121
For example, is a telemedicine network or system defined by a geographical area,
by the technology, by the healthcare provider, by the actual clients or by a set of eligible
clients?
A telemedicine network is generally defined by geography and technology. In
Figure 13, The University of Tennessee Telemedicine Network, the hub site is connected
to the spoke sites by T-1 lines (dedicated phone connections that support data
transmission rates of 1.544 Mbits per second), ISDN lines (integrated services digital
network), and POTS (plain old telephone system).
59
University of Tennessee
Telemedicine Network
Õ Ja mestown
Ø Hun tsville Õ Lafolle tte
Ø
Bla ine Ø
W ashb urn
P
Etow ah
0
Ø Rutle dge
Õ Mo rristo wn
Kn oxville
Õ
50
100 Miles
P
HUB S ITE, UT Medic al Center, K nox ville
Õ
HOSP ITA L SPO KE S ITE S
LaFollette Medic al Center
Fentres s County Hospital, Jamestown
Morristown-Hamblen Healthcare System
W oods Memorial Hospital, E towah
Ø
CLINIC S POKE SITES
Blaine Medic al Clinic
Hunts ville Mountain P eoples Clinic
Rutledge Medical Clinic
W ashburn Medical Clinic
Figure 13.
Telemedicine Network (2000), Geographic Model
121
Ibid.
60
The hub site is typically in a large, regional hospital or medical center, although it
could be located in a specialist‟s office or in a specialty department, such as a regional
trauma center. The spoke sites are located in a wide variety of settings including smaller
community hospitals or clinics, schools or other community buildings, health care
professional offices, nursing homes, prisons, private residences, or in mobile units in
ambulances, helicopters, airplanes, or ships.
For the purposes of this study, a telemedicine network is defined primarily by the
healthcare providers, the healthcare clients, and the persons who assist in their virtual
encounter (proposed Telemedicine Clinical Network Model, Figure 14). Although it
plays an important role, the technology is merely the conduit that makes the virtual
encounter possible.
The hub site specialist(s) could be a physician specialist, nurse practitioner
specialist, nurse specialist, allied health care specialist (therapist, nutritionist, etc.), and/or
medical education or training specialist.
The healthcare client is typically a patient accompanied by a presenter, usually a
nurse or another healthcare professional, or the patient and/or caregiver in a home-health
setting. Healthcare clients may also be a student or another healthcare professional.
The interactive encounter, symbolized by the two-way arrow, could be a patient
consultation with medical specialist(s), a consultation between healthcare professionals, a
continuing medical education or training session, or public health education session.
61
The encounters could also include tele-homecare and/or tele-monitoring by a homecare
nurse and transmission of digital data.
Hub Site
HealthCare Specialist(s)
•Hub Staff
•Technical Support Staff
•Referring Physician
•Referring Support Staff
Spoke Site
HealthCare Client(s)
and/or Presenter(s)
Figure 14.
Telemedicine Network, Clinical Model
62
Case Selection Criteria
Yin recommends a logical selection of case studies, instead of sampling, because
typically, case study research involves in-depth study of a small number of specific types
of cases chosen to address specific questions of “how” and “why.”
For this study, two cases were selected from each of four types of
telemedicine/telehealth organizations: academic medical centers, non-academic medical
centers or networks, statewide telemedicine networks, and telemedicine programs located
within a health insurance company.
Selection criteria include length of time in operation (at least three years),
geographic diversity, and quantity and availability of published documentation associated
with the telemedicine network determined by bibliographic analysis.
The two key informants from telemedicine programs located within health
insurance companies were reluctant to have their corporate identities revealed, in part
because of corporate proprietary information, so they will be identified as Insurer-based
One and Insurer-based Two.
Selected Cases
Academic Medical Centers
1) Arizona Telemedicine Program
1501 N. Campbell, Tucson, AZ 85724-5105
63
2) East Carolina University Telemedicine Program
1S-10 Brody Bldg., Greenville, NC 27858
Non-Academic Medical Centers or Networks
3) Eastern Montana Telemedicine Network
PO Box 37000, Billings, MT 59107
4) Marshfield Clinic TeleHealth Network
1000 N. Oak Avenue, Marshfield, WI 54449
Statewide Telemedicine Networks
5) Center for TeleMedicine and TeleHealth
The University of Kansas Medical Center
3901 Rainbow Blvd, 2012 Wahl Annex Bldg., Kansas City, KS 66160
6) Missouri Telehealth Network
2401 Lemone Industrial Blvd. DC 345.00
Columbia, MO 65212
64
CHAPTER IV
RESULTS
Introduction
General information about each program was obtained from the programs‟ Web
sites, research publications, Telemedicine Information Exchange Database and the Office
for the Advancement of Telehealth Grantees Directory. 122
The telemedicine programs‟ mission statements, goals, and/or objectives were
obtained from the organizations‟ Web sites or other official publications. In some cases,
the mission, goals, and/or objectives were specific to telemedicine. In other cases, the
telemedicine program followed the mission of the parent organization. For consistency,
the parent organizations‟ mission statements are included.
To insure accuracy of the transcripts, interview transcriptions and the results of
the interview analyses were sent to the key informants for review. No major changes
were needed, but many minor changes or additions for clarification were suggested by the
key informants. Data from the interview analyses were then triangulated and crosschecked for accuracy using organizational publications, research reports, and federal
grant progress reports obtained through the Freedom of Information Act.
Office for the Advancement of Telehealth, “OAT Grantee Directory: FY 2000,” U.S. Department of
Health and Human Services, Health Resources and Services Administration (2000), 13.
122
65
Mission Statement, Goals, Objectives
Academic Medical Systems
Arizona (Sites, Figure 15)
The Arizona Telemedicine Program uses interactive and store
and forward technologies to connect 28 sites within Arizona. Of the
14 full service sites, seven are in health professional shortage areas
and six are Department of Corrections sites…. service area includes
the Hopi, Navajo, and Apache Nations. The network has been operational
since May of 1997.
The network plans to expand services to all state correctional
facilities. The network also has an active home health project in
pre-heart transplant care and osteomy/wound management.123
Arizona Health Sciences Center Mission
The mission of the Arizona Health Sciences Center (AHSC) is to
provide health care education, research, patient care and service for the
people of Arizona. Our faculty, staff and students consistently fulfill that
mission by offering their expertise in health care programs throughout
Arizona. One such program allows nursing, pharmacy and medical students
to take part in statewide rural rotations, living and learning in areas ranging
from the U.S.-Mexico border to Native American communities in Northern
Arizona.124
123
Ibid., 13.
Arizona Health Sciences Center, “AHSC Mission” Available at
http://www.ahsc.arizona.edu/welcome/ahsc_mission.html
124
66
= Department of Corrections Site
= Rural Site
= Indian Health Services Site
Figure 15.
Arizona Telemedicine Program Sites125
University of Arizona, Arizona Telemedicine Program, “Arizona Telemedicine Program Sites,” (May 3,
2001). Available at http://www.telemedicine.arizona.edu/program/sites.html
125
67
Arizona Telemedicine Goals
To enhance health care delivery to medically underserved populations
throughout the state using telemedicine technologies
To establish a statewide Arizona Rural Telemedicine Network
To increase access to medical specialty services while decreasing health care
costs
To use telemedicine outreach programs to encourage physicians, nurses, and
other health care professionals to establish practices in underserved rural areas
To provide ongoing training for preceptors, medical students, and residents
To recruit students from rural communities into the health care professions
and encourage their return to these communities upon completion of their
educations
To improve public health in rural communities by providing current
information and training for rural county health departments
To have the Arizona Rural Telemedicine Network serve as a test bed for
various state agencies to evaluate the effectiveness of state-of-the-art
telemedicine services
To increase and promote the use of telecommunications for distance learning
in health care
To provide health care systems throughout the state with information, training,
and expertise in the field of telemedicine
To evaluate telemedicine equipment and telecommunications options and
participate in their development
To perform telemedicine needs assessments for state agencies
To expand current undergraduate, graduate, and postgraduate education
programs in telemedicine
To support and promote the economic development of the State of Arizona
(e.g., Senior Living Program, etc.). 126
Arizona Telemedicine Program, “Arizona Telemedicine Program Goals,” (May 3, 2001). Available at
http://www.telemedicine.arizona.edu/program/goals.html
126
68
East Carolina University Telemedicine Center (Sites, Figure 16)
The East Carolina University (ECU) Telemedicine Center
began providing telemedicine services in 1992. The current network
consists of 22 interactive conference and clinical sites plus four storeand-forward sites and two tele-mental health networks. The newest
site is a link to the North Carolina School for the Deaf for pediatric
care and child psychiatry.
In addition to many medical specialties, the network provides
non-physician services, such as diabetes management, speech pathology,
pharmacy, social services, nutrition clinics, and various clinical nurse
specialist services. The network is used often for supervision of health
professional students and residents, continuing education and administrative meetings.127
East Carolina University Medical Center Mission
The Medical Center has the mission to promote and facilitate
Service, Education, and Research in health care throughout the region. 128
ECU Telemedicine, Institute for Interventional Informatics (I3) Goals
1. Integration of I3 technologies for disabled persons
2. Integration of I3 technologies into home health and telemedicine situations
3. Development of a team that continues to import and develop these
technologies as part of a new CHSC Rapid Prototyping Center modeled after
the I3 method
4. Continue to establish and maintain social cohesion and collaboration between
I3 and CHSC
127
Ibid., 43.
ECU Joyner Library, “Medical Center Mission Statement,” (November 20, 2000). Available at
http://www.lib.ecu.edu/SpclColl/Archives/pr104.html
128
69
5. Continue to establish collaborations within the university to promote
production of projects 129
Figure 16.
ECU Telemedicine Sites130
ECU Telemedicine Center, “Interventional Informatics Goals,” (August 14, 2001). Available at
http://www.telemed.med.ecu.edu/2001/interventional/goals.htm
129
East Carolina Telemedicine Network, “Site Map.” Available at
http://www.telemed.med.ecu.edu/2001/sitemap/
130
70
Non-academic Medical Systems
Eastern Montana Telemedicine Network (Sites, Figure 17)
Operational since September of 1993, the Eastern Montana
Telemedicine Network is a consortium of 15 not-for-profit medical and
mental health facilities. From July 1999 to June 2000, a total of 1,825 videoconferences were conducted over EMTN with over 12,000 participants.
In addition … the network has conducted clinical services in
pathology, gastroenterology, pediatrics and ENT. Other clinical applications
include registered dietician services, employee assistance counseling and
geriatric assessment services. Medical and mental health services represent
over 60 percent of the total activity on the network. The system is also
used for educational programs, administrative and tele-business services,
and supervision of family practice residents during their rural rotations.
Through the planned addition of North Big Horn Hospital in
Wyoming, a connection to the Shriners Children‟s Hospital in Utah will
be made twice a month for assessment and follow-up services to orthopedic
and burn patients living in the Basin area of Wyoming.” 131
Eastern Montana Deaconess Billings Clinic Mission
Deaconess Billings Clinic‟s mission is to improve the health of the
citizens of our region through health care, education and research. As a
not-for-profit organization, care is provided regardless of ability to pay. 132
Eastern Montana Telemedicine Network Goal
To utilize two way interactive video conferencing technology
to deliver specialist medical and mental health services, continuing medical
and higher education, administrative and tele-business services regionally
and nationally.133
131
Office for the Advancement of Telehealth, 35.
Eastern Montana Telemedicine Network, “EMTN Network Office, Deaconess Billings Clinic.”
Available at http://www.emtn.org/site2_1.html
132
Eastern Montana Telemedicine Network, “EMTN Summary.” Available at
http://www.emtn.org/summary.html
133
71
Figure 17.
Eastern Montana Telemedicine Network Sites134
1. Fallon County County Medical Complex, Baker, Montana
2. Yellowstone County – Billings, Montana
EMTN Office at Deaconess Billings Clinic
Deaconess Billings Clinic Behavioral Health Clinic
Yellowstone City-County Health Department
Montana Family Practice Residency
3. Custer County
Eastern Montana Community Mental Health Center, Miles City, Montana
4. Dawson County – Glendive Medical Center
5. Richland County – Sidney Health Center
6. Roosevelt Memorial Hospital and Nursing Home, Culbertson, Montana
7. Lewis & Clark County – Helena, Montana
Montana Healthcare Association
8. Rosebud County – Colstrip Medical Center
9. Valley County – Glasgow, Montana
Frances Mahon Deaconess Hospital
134
Eastern Montana Telemedicine Network, “EMTN Sites.” Available at http://www.emtn.org/sites.html
72
Marshfield Clinic TeleHealth Network (Sites, Figure 18)
Since 1997, the Marshfield Clinic TeleHealth Network has
supported an integrated system of health care delivery in 39 regional centers.
Six Marshfield Clinics provide consultants who practice medicine over the
network in eleven other regional centers, one affiliated hospital as well
as one independent physician service organization and rural hospital.
In addition to the services listed above, the network has provided consultations in plastic surgery, neurology (sleep studies, snoring assessments),
and emergency services. The system is also used for business and operational
meetings, as well as CME and community education. The network is the
only medical facility linked to BadgerNet, the statewide video conference
and educational system.
Marshfield Clinic has assisted the St. Paul Regions Hospital Burn Center
in conducting follow-up care of burn patients. In the next two years, the network
will expand to schools and long term care facilities, including nursing homes,
home health and hospice.135
Marshfield Clinic, Mission
The mission of Marshfield Clinic is to serve patients through
accessible, high quality health care, research and education.136
Marshfield Clinic Objectives
135
Customer Focus: The services we provide will be determined by the needs of
the customer
People Orientation: We will treat our people as Marshfield Clinic‟s most
important asset
System Integration: Marshfield Clinic will be an integrated, synergistic health
care delivery system
Office for the Advancement of Teleheatlh, 68.
Marshfield Clinic, “Mission Statement” (February 2002). Available at
http://www.marshfieldclinic.org/home/about/mission.stm
136
73
Financial Stability: Marshfield Clinic will attain and maintain financial
stability. 137
Figure 18.
Marshfield Clinic Sites138
= Marshfield Clinic Hub Site
137
Ibid.
74
State-wide Telemedicine Networks
Kansas Center for TeleMedicine and TeleHealth (Sites, Figure 19)
The Center for TeleMedicine & TeleHealth at the University of Kansas
Medical Center is a pioneer in telemedicine activity and research. In the late
eighties and early nineties, the idea of telemedicine and its practice were coming
together to serve a rural population desperately lacking access to medical
services. Inspired by this challenge, affiliates at the Kansas University Medical
Center began creating a telecommunication network that would reach underserved Kansans throughout the state. Remarkably, in 1999 alone the
TeleMedicine program conducted 2,207 consultations making it one of the
top five most active telemedicine sites in the world.
In 1999, KU received the prestigious President‟s Award presented by
the American Telemedicine Association for historic contributions in the
advancement of telemedicine. Delivering health services, both clinical and
educational, through telemedicine technologies raises a plethora of questions,
ranging from efficacy to cost benefit issues. KU‟s Center for TeleMedcine and
TeleHealth‟s team of researchers seeks to broaden universal knowledge of
telemedicine by demanding rigorous study of this application, rather than the
traditional dependence on anecdotal evidence.
In its first 8 years, affiliates of KUCTT have published more than 100
research-based articles in more than 30 academic and research journals.139
University of Kansas Medical School Mission
Quality education for medical students and residents to become competent,
compassionate physicians, and continuing medical education to maintain
proficiency;
Marshfield Clinic, “Marshfield Clinic Centers.” Available at
http://www.marshfieldclinic.org/centers/map.asp
138
The University of Kansas Medical Center, Center for Telemedicine and TeleHealth, “History” (2001).
Available at www2.kumc.edu/telemedicine/history.html.
139
75
Improved medical services for the people of Kansas, particularly in
underserved communities; and
A supportive environment for biomedical research.140
Figure 19.
Kansas University Center for TeleMedicine and TeleHealth
ITV Sites141
University of Kansas Medical Center, “Mission Statement.” Available at
http://wichita.kumc.edu/info/mission.html
140
University of Kansas, Center for TeleMedicine and TeleHealth, “ITV Sites.” Available at
http://www2.kumc.edu/telemedicine/itvcom.html
141
76
Kansas University Center for TeleMedicine and TeleHealth Mission
Provide clinical services to Kansans using cutting-edge technologies
Provide wellness education to Kansans and professional education to Kansas
health professionals using cutting-edge technologies
Serve as a site for research and development in the delivery of clinical and
educational services using cutting-edge technologies.142
Kansas University Center for TeleMedicine and TeleHealth Goals
Seek opportunities to apply TeleMedicine and TeleHealth tools and methods
to improve the delivery of healthcare
Support the development of a TeleHealth network in Kansas
Support the delivery of KUMC clinical services through TeleMedicine
Use TeleMedicine and TeleHealth tools and methods to provide professional
development to healthcare providers and health and wellness information to
healthcare consumers
Conduct research into the efficacy, cost, and implementation of TeleHealth
delivery
Participate in the development of state and national policy related to
TeleHealth
Evaluate new information and communications technologies for possible
integration into the TeleHealth toolkit and develop related clinical delivery
models as appropriate.143
University of Kansas Medical Center, Center for Telemedicine and TeleHealth, “Our Mission.”
Available at http://www2.kumc.edu/telemedicine/mission.html
142
143
Ibid.
77
Missouri Telehealth Network (Sites, Figure 20)
University of Missouri Health Care is the hub site for the Missouri
Telehealth Network (MTN), which covers a geographic area representing
approximately 22 percent of the state‟s rural population. Four of the 16 rural
counties where MTN operates are federally designated Health Professional
Shortage Areas. MTN has been operational since the summer of 1995.
In terms of rural services, the network provides both teleradiology and
interactive video encounters to six sites, interactive video services to nine sites,
and teleradiology services for three sites. MTN has two sites that are part of the
Area Health Education Center (AHEC) network: an urban site in St. Joseph and a
rural site in Rolla. MTN provides services to special populations, such as children
with special needs and traumatic brain injury patients.144
University of Missouri Healthcare Mission
As part of a land-grant university, University of Missouri Health
Care's core mission is to provide education, research and service to the
residents of Missouri with an emphasis on rural Missouri.145
University of Missouri Healthcare Vision
To offer programs of unsurpassed excellence that will be integrated
into a highly efficient, fiscally sound, professionally outstanding, serviceoriented health system that is unified in a common purpose to be one of
the premier comprehensive academic health systems in the nation.146
144
Office for the Advancement of Teleheatlh, 37.
University of Missouri Healthcare, “Mission and Vision of MU Healthcare,” (November 9, 2001).
Available at http://www.muhealth.org/~center/missionvision.shtml
145
146
Ibid.
78
Figure 20.
Missouri Telehealth Network Sites147
1. Putnam County Memorial Hospital,
10. Ellis Fischel Cancer Center, Columbia
Unionville
10. University of Missouri-Health Sciences
2. Scotland County Memorial Hospital,
Center, Columbia
Memphis
11. Cooper County Memorial Hospital,
3. Sullivan County Memorial Hospital,
Boonville
Milan
12. Callaway Physicians, Fulton
4. Kirksville College of Osteopathic
13. Phelps County Regional Medical
Medicine, Kirksville
Center*, Rolla
5. Pershing Memorial Hospital*, Brookfield
14. Missouri Rehabilitation Center, Mount
6. Loch Haven Nursing Home, Macon
Vernon
6. Samaritan Memorial Hospital*, Macon
15. Capital Region Medical Center,
7. Keytesville Clinic, Keytesville
Jefferson City
8. Moberly Regional Medical Center,
16. Heartland Health System, St. Joseph
Moberly
17. General Fort Leonard Wood Hospital,
9. Fayette Medical Clinic, Fayette
Ft. Leonard Wood
Missouri Telehealth Network, “MTN Sites.” Available at
http://www.muhealth.org/~telehealth/geninfo/sites.shtml
147
79
Insurer-Based Programs
Insurer-based One Telemedicine Demonstration Project
Insurer-based One is a statewide telemedicine demonstration project designed to
increase access to specialty care. The program was made possible through a $1.8 million
Rural Health Demonstration Project award as part of a state-sponsored insurance program
offering low-cost health, dental and vision coverage to children of low-income working
families.
The telemedicine program uses computer technology and the existing insurance
network to help physicians expand access to quality healthcare and erode the barriers of
distance, time, cost, and language that have prevented people in medically underserved
rural areas from receiving state-of-the-art diagnosis and treatment.
Rural Telemedicine Demonstration Project Goals
1. Expand access to specialty health care services for rural residents
Objective 1: increase availability of specialists
Objective 2: build utilization in specialty provider shortage areas
Objective 3: improve access for members in medical groups
2. Evaluate the acceptability of TM and the impact on care from a patient and
provider perspective
Objective1: quantify the acceptability of using telemedicine by patients and
providers
Objective 2; identify the impact on care from a provider perspective
Objective 3: quantify changes in cost, distance and time for patients using TM
3. Develop a sustainable telemedicine model
Objective 1: develop reimbursement policy
Objective 2: develop claims and billing methodology. 148
80
Insurer-based Two E-Health
Insurance-based Two is one of the nation‟s largest nonprofit health maintenance
organizations. To leverage its size and information assets, in 1996, it restructured its
information technology organization from regional operations to a national structure to
deploy and share information across the country.
Insurer-based Two members in certain areas of the country can access drug and
medical encyclopedias, request appointments, and ask confidential questions of advice
nurses and pharmacists. They can also access health plan benefit options, research local
health education classes, access physicians‟ directories, and directions to facilities.
E-Health Goal
Insurer-based Two Interactive Technologies Initiative‟s goal is extending patientdriven service to the benefit of choice, access, quality and ever improving relations
between its clinicians and members.
Comments
All of the organizations in this study include education, research, and either
service or healthcare in their mission statements. The six telemedicine or telehealth
programs that have telemedicine-specific missions, goals, and/or objectives mention
81
increasing or expanding the delivery, enhancement, or access to healthcare, and three
specify increasing healthcare delivery to underserved or disabled populations.
Background Questions
1. What is the official name of your telemedicine/telehealth system?
2. Is that the original name or has the name changed over time?
Five of the eight programs contain the term “telemedicine” in their names,
including the two academic medical systems, Arizona Telemedicine Program and East
Carolina University Telemedicine Program, and one each in the other three categories,
Eastern Montana Telemedicine Network (non-academic medical system), Kansas
University Center for TeleMedicine and TeleHealth (state-wide network), and InsurerBased One Rural Telemedicine Demonstration Project.
Three use the term “telehealth,” one non-academic health system, Marshfield
Clinic TeleHealth Network, and both state-wide networks, Missouri Telehealth Network,
and Kansas University Center for TeleMedicine and TeleHealth, which incorporates both
terms. Insurer-Based Two‟s system is known as “E-health.”
Both the academic medical system telemedicine programs have alternative names
for their network communications infrastructure. Arizona Telemedicine Program
Network is also known as Arizona Rural Telemedicine Network (ARTN) and East
Carolina‟s program also known as REACH-TV (Rural Eastern Carolina Health
Television).
82
Five of the eight systems, both academic, both non-academic and one insurerbased, continue to use their original names. Both state-wide networks had a name change.
Missouri Telemedicine Network became Missouri Telehealth Network. Kansas
Telemedicine became Information Technology Services and Research (ITSR) then
Kansas University Center for TeleMedicine and TeleHealth. Insurer-based Two program
changed from “Tele-Homecare” to “E-health.”
3. When and how did telemedicine begin in your organization? (Figure 21)
Academic Medical Systems
In 1996, the University of Arizona Medical School was given a mandate and
funding by the state legislature to develop a telemedicine program that would provide
healthcare services to rural communities, Indian tribes, and rural prisons.
East Carolina University already had a distance learning program when the state‟s
largest prison contracted with ECU School of Medicine to provide telemedicine services
beginning in 1992.
Non-Academic Medical Systems
Eastern Montana‟s Deaconess Billings Clinic outreach services began
investigating the possibility of using interactive video as a pilot project in 1992. A Rural
Utilities Services grant funded equipment for the first five rural sites that became
operational in 1993, while an in-house grant funded Deaconess Billings Clinic as the
telemedicine hub site.
83
Wisconsin‟s Marshfield Clinic TeleHealth Network was developed in 1997 with a
$1 million grant from the Office of Rural Health Policy to increase access to specialty
healthcare services in remote areas of northern, central and western Wisconsin.
Figure 21.
Timeline of Telemedicine Programs by Year They Began
ECUTC = East Carolina University Telemedicine Center
EMTN = Eastern Montana Telemedicine Network
MTM = Missouri Telehealth Network
KUCTT = Kansas University Center for TeleMedicine and TeleHealth
Ins2 = Insurance-Based Telemedicine Program
ATP = Arizona Telemedicine Program
MCTN = Marshfield Clinic TeleHealth Network
Ins1 = Insurance-Based Telemedicine Program
84
State-wide Telemedicine Networks
The University of Kansas Medical Center began with educational services, then in
1993 began offering clinical services over the system. In 1995, the state legislature
provided funding for a staff at the Medical Center to support telemedicine clinical
activities.
Missouri Telehealth Network began in 1993 as a collaborative effort in the
University of Missouri-Columbia School of Medicine‟s Department of External Affairs,
the Missouri Public Service Commission, Southwestern Bell, GTE, AT&T, Northeast
Missouri Rural Telephone and ALLTEL Missouri to understand how advanced
telecommunications technologies could improve access to quality medical care. In 1994,
an Office of Rural Health Policy grant and support from telephone companies created one
of the largest public-private telemedicine partnerships in the nation.
Insurer-Based Systems
In 1999, Insurer-based One was awarded a $1.8 million grant from a state fund to
establish a telemedicine demonstration project to enhance the quality of healthcare to
rural populations including migrant workers and Native Americans.
In 1995, Insurer-based Two Interactive Technologies Initiative (ITI) began a pilot
Tele-Home Health project in response to a shortage of healthcare providers and with the
goal of improving member access to quality healthcare.
85
4. Was any sort of needs assessment done in the beginning stages?
A formal needs assessment was conducted by only three of the eight systems, one
academic-based, one non-academic based, and one insurer-based program.
Arizona Telemedicine conducted needs assessments and tested technology for
eight months before becoming operational. Marshfield Clinic TeleHealth based its
program design on needs assessments in two rural Wisconsin counties. According to the
key informant for Insurer-based One, needs assessments were conducted to identify
provider shortage areas prior to telemedicine sites being chosen.
The five programs that did not conduct formal needs assessments cited reasons
such as the obviousness of the need to improve access to medical care, healthcare
provider shortages, and the documentation of subspecialty needs in rural areas.
5. Is telemedicine a separate department or is it integrated into other departments?
The two insurer-based programs and one non-academic medical system,
Marshfield Clinic, are the most integrated within their organizations. The telemedicine
program itself is run by only one or two persons who facilitate the integration of
telemedicine throughout the system by using their organizations‟ resources.
The second non-academic medical system, Eastern Montana, is a network, a
consortium of twenty not-for-profit members whose hub site is the main clinic in the
system.
86
Both academic medical systems telemedicine programs are a separate program
located within their medical schools, Arizona within the Department of Pathology and
East Carolina within the Department of Health Communications.
Both state-wide telemedicine systems are headquartered in state university
medical schools, Kansas within the Department of Information Technology and Missouri
within the Department of External Affairs.
6. How many full-time employees work in your telemedicine system?
7. How many part-time employees? (Table 3)
Academic Medical Systems
Arizona Telemedicine employs twenty-two, including four full-time employees,
two telemedicine coordinators, a distance education coordinator and an administrative
assistant. Grants fund about 90 percent of the associate director, 50 percent of the
medical director and chief information officer, and 40-50 percent of the three
telemedicine technicians.
East Carolina Telemedicine Center is headed by a director and has a large staff
that includes a telemedicine grants project manager, a distance education coordinator,
four telemedicine program coordinators, two telemedicine training coordinators, two
telecommunications engineers and two media technicians. In addition, for the National
Library of Medicine Next Generation Internet Project, there is a project manager, a
project assistant, a network telecommunications engineer, and an evaluation/research
director.
87
Table 3.
Telemedicine Program by Number of Employees
Full-time
Part-time
Arizona
4
18
ECU
17
2
E Mont.
4
.5 per site
Marshfld 3
4
Kansas
13
2
Missouri
4
4
Ins1
CCI*
CCI*
Ins2
CCI*
CCI*
*CCI = Company Confidential Information
88
Non-academic Medical Systems
Eastern Montana has four full time employees, a telemedicine director, two
telemedicine technicians and a telemedicine RN. Each site supports a .5 FTE as part of
their commitment to membership in the telemedicine network.
Marshfield Clinic TeleHealth is headed by a program manager. Two telemedicine
medical clinicians are supported by grant funding. The other employees are funded
internally by the clinic, including human resources drawn from the organization as time
commitments, such as an estimated .2 medical director, a .2 administrative director, a .2
information services personnel, and a .2 scheduler.
State-wide Telemedicine Networks
Kansas telemedicine has thirteen full-time employees, including four project
managers, a project coordinator, two video technicians, a media production manager, and
two part-time research assistants.
Missouri telemedicine has four full-time employees, an executive director, an
assistant director, an administrative associate and an administrative assistant. Four parttime employees include a coordinator of program and project support, a continuing
education coordinator, a network support specialist, and a user support analyst.
Insurer-based Programs
Insurer-based One‟s Telemedicine Demonstration Project has two full-time
employees, a clinical research manager and a business development manager.
89
Insurer-based Two‟s E-Health is overseen by an e-health manager who uses
organizational resources to integrate e-health throughout the system.
Both key informants from insurer-based systems were reluctant to identify or
even estimate the number of medical personnel within their systems involved in
telemedicine or telehealth.
8. Using Grigsby’s classification scheme,149 which general applications and processes
of telemedicine do your organization provide? (Table 4)
a. Initial urgent evaluation and triage
b. Medical and surgical follow-ups
c. Primary care consultations
d. Specialty consultations and second opinions
e. Transmission of digital diagnostic images
f. Diagnostic work-ups for specific conditions
g. Monitoring of chronic diseases and conditions
h. Transmission of medical data
i. Public health and education
149
Jim Grigsby, Robert E. Schlenker, Margaret M. Kaehny, Peter W. Shaughnessy, and Elliot J. Sandberg,
“Analytic Framework for Evaluation of Telemedicine,” Telemedicine Journal 1 (1995), 36-37.
90
Arizona
Table 4.
Telemedicine Program by General Applications
a.
b.
c.
d.
e.
f.
g.
Triage Med- Prim Spec.
Trans Diag Monitor
F/U
care consult images W/U
Yes
Yes
No
Yes
Yes
Yes Yes
h.
Trans
data
Yes
i.
Pub
Hlth
Yes
ECU
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
E Mont.
Yes
Yes
No
Yes
Yes
Yes
Dev*
No
Yes
Marshfld Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Kansas
Yes
Yes
Yes
Yes
Dev*
Yes
Yes
No
Yes
Missouri
No
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Ins1
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Ins2
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
*Dev = In development
9. Using Reid’s classification scheme of telemedicine (Level of Service, Setting,
Healthcare Discipline, Technology Used, Equipment, Activity Conducted),150 what
level of service(s) does your organization provide? (Table 5)
a. Tele-Consultation
b. Tele-Care
c. Tele-Monitoring/Mentoring
d. Telehealth Education
e. Other
Jim Reid, “Telemedicine Applications: Today and in the Future,” slide presentation (1998). Available at
www.telemedprimer.com/htb1198/tsld001.htm.
150
91
Other Services
The two insurer-based programs both have a virtual library of online health
information resources.
10. What are the settings (end-user locations)? (Table 6)
a. Hospital
b. Clinic
c. Home
d. Prison
e. Workplace
f. Other
92
Table 5.
Telemedicine Program by Level of Service
a. Tele- b. Telec. Teled. Telehlth
Consult Care
Monitoring Education
Yes
Yes
Yes
Yes
Arizona
ECU
Yes
Yes
No
Yes
E Mont.
Yes
Yes
No
Yes
Marshfld
Yes
Yes
No
Yes
Kansas
Yes
Yes
No
Yes
Missouri
Yes
No
No
Yes
Ins1
Yes
No
No
Yes
Ins2
Yes
Yes
Yes
Yes
93
Arizona
Table 6.
Telemedicine Program by Setting
a.
b.
c.
d.
e.
Hospital Clinic Home Prison Work
Yes
Yes
Yes
Yes
No
f.
f. Nursing
School Home
Yes
No
ECU
Yes
Yes
Yes
Yes
No
Yes
No
E Mont.
Yes
Yes
Dev*
No
No
No
No
Marshfield Yes
Yes
Yes
Dev*
No
Yes
Yes
Kansas
Yes
Yes
Yes
No
No
Yes
Dev*
Missouri
Yes
Yes
No
No
No
No
Yes
Ins1
No
Yes
No
No
No
No
No
Ins2
Yes
Yes
Yes
No
Dev*
No
No
*Dev = In development
94
Additional Sites
Arizona‟s telemedicine program is multicultural, offering services to Native
American and Hispanic communities. ECU Telemedicine spoke sites include mental
health clinics, a school for the deaf, and a planned connection to a mental health hospital.
Insurer-based One has five specialty hub sites and thirty-eight primary care clinic
spoke sites throughout the state.
Eastern Montana Telemedicine has a spoke unit in the Montana Hospital
Association headquarters. Marshfield Clinic has spoke sites in dialysis clinics as well as
physician clinics.
Kansas Telemedicine sites include community mental health clinics. Missouri
Telehealth sites include two health education centers for third-year hospital residents in
rural areas.
11. What healthcare disciplines use your telemedicine system?
a. Medical specialty (Family Practice, Dermatology, etc.)
b. Nursing (Acute care, Home health, Hospice)
c. Allied health (PT, OT, Nutritionist, etc.)
d. Other
Academic Medical Systems
Arizona Telemedicine offers fifty-three medical specialties, the top five of which
are radiology, pathology, dermatology, psychology and cardiology. The telemedicine
95
network offers wound management and ostomy nursing specialties and allied health, such
as physical therapy, to children with specific healthcare needs.
East Carolina Telemedicine offers more than thirty specialties. The main ones are
dermatology, cardiology, psychology, pulmonary, endocrinology, obstetrics, rehab, and
allergy.
Non-academic Medical Systems
All of the specialists at Deaconess Clinic are available for the Eastern Montana
Telemedicine, including dermatology, neurology, orthopedics, pathology, radiology,
pediatrics, emergency medicine, internal medicine, oncology, infectious disease,
gastroenterology, neurology, burn care and mental health services. The top specialties of
the telemedicine network are mental health; ear, nose, throat; and diabetes education.
Nursing specialties include diabetes education and cardio-vascular follow-up care. Two
nutritionists work collaboratively with the diabetic education nurse.
Marshfield Clinic TeleHealth offers specialty services in dermatology, oncology,
occupational therapy, occupational medicine, burn management, cardiology, child
psychiatry, clinical psychology, clinical social work therapy, diabetes management,
disease-state management, employee assistance counsel, emergency services,
nephrology, neurology, nutrition, plastic surgery, psychiatry, speech pathology. Nursing
specialties include home healthcare, disease-state management, nurse triage, high-risk
obstetric assessment, general internal medicine and jail services. Allied health specialties
include occupational therapy, speech therapy, and nutrition.
96
State-wide Telemedicine Networks
The Kansas Center for TeleMedicine and TeleHealth offers tele-psychiatry, teleoncology, tele-hematology, tele- rheumatology, and allergy/immunology telemedicine.
The busiest is a pediatric program offered in Kansas schools, TeleKid Care ®.151 Nursing
specialties include the previously listed medical specialties as well as tele-hospice care.
Allied specialists include occupational therapists and social workers
The top specialties at Missouri Telehealth are tele-radiology, tele-dermatology
and three types of tele-psychiatry: adult, child, and geriatric. In addition, Missouri
Telehealth offers services in cardiology, children with special needs, emergency
medicine, neurology, OB/GYN, orthopedics, physical medicine and rehabilitation,
surgical follow-up, and wound care. MTN has also done some work in the areas of child
health, endocrinology/diabetes, and nephrology.
Insurer-based Systems
Insurer-based One offers twenty-seven specialty categories. Top specialties are
dermatology, endocrinology, psychiatry, neurology, especially pediatric neurology, and a
combined infectious disease/hepatology.
Insurer-based Two offers tele-radiology, tele-dermatology, tele-rehab and disease
management medical specialties. Nursing specialties offered include home health,
hospice, wound care, and enterostomal therapists.
University of Kansas Medical Center, Center for TeleMedicine & TeleHealth, “TeleKid Care®.”
Available at http://www2.kumc.edu/telemedicine/tkc.html
151
97
12. What telemedicine technology system(s) are used by your organization?
(Table 7)
a. Interactive video
b. Store & Forward
c. Other
13. What kind(s) of equipment is used in this system? (Table 8)
a. Room systems
b. Rollabouts
c. PCs
d. Mobile
e. Set top boxes
f. Other
98
Table 7.
Telemedicine Program by Technology
a. Interactive Video
b. Store & Forward
Arizona
Yes, 40%
Yes, 60%
ECU
Yes
Yes
E Mont.
Yes, 100%
No
Marshfield
Yes, 100%
No
Kansas
Yes, 100%
No
Missouri
Yes, all non-radiology
Yes, tele-radiology
Ins1
Yes, most
Yes
Ins2
Yes, 100%
No
99
Table 8.
Telemedicine Program by Equipment
a. Room
Systems
b. Rollabouts
c. PCs
d. Mobile
e. Set-top
Boxes
Arizona
Yes
Yes
Yes
No
Yes
ECU
Yes
No
Yes
No
Yes
E Mont.
Yes
Yes
No
No
No
Marshfield
Yes
No
Yes
No
Yes
Kansas
Yes
Yes
Yes
No
Yes
Missouri
Yes
No
Yes
No
Yes
Ins1
No
Yes
Yes
No
No
Ins2
Yes
No
Yes
Yes
Yes
100
14. What kind of activity is conducted with telemedicine in your organization?
(Table 9)
Clinical
Administrative (Meetings, Recruitment, Compliance Q&A)
Educational (Adult, Medical, Nursing, Allied)
Business (Community business, Social orgs, Government orgs)
Other
15. How is your telemedicine system funded? (Table 10)
a. Grants
b. In-house
c. Insurance reimbursement
d. Other
Additional Sources of Funding
East Carolina and Eastern Montana receive fees from their network spoke sites.
Additionally, East Carolina has a telemedicine training program that generates income.
Both insurer-based programs are funded internally, as well as by grants. Insurerbased Two additionally receives funding from public pharmaceutical companies.
101
Three programs are funded by their state legislatures. Arizona and both state-wide
programs, Kansas and Missouri are funded by federal grants as well as by their respective
state legislatures.
Table 9.
Telemedicine Program by Activity
a.
Clinical
b.
Educational
c.
d.
Administrative Business
Arizona
Yes
Yes
Yes
No
ECU
Yes
Yes
Yes
No
E Mont.
Yes, 65%
Yes, 25%
CME*
Yes
Yes
Marshfield Yes
Yes
Yes
Yes
Kansas
Yes
Yes
Yes
No
Missouri
Yes
Yes, CME*
Yes
No
Ins1
Yes
Yes, Pt &
CME*
Yes
Yes
Ins2
Yes
Yes
Yes
Yes
*CME = Continuing Medical Education
102
Table 10.
Telemedicine Program by Funding Source
a.
Grants
b.
In-House
c.
Insurance
d. State
Legislature
Arizona
Yes
Yes
Yes
Yes
ECU
Yes
Yes
Yes
No
E Mont.
Yes
Yes
Yes
No
Marshfield Yes
Yes
Yes
No
Kansas
Yes
Yes
Yes
Yes
Missouri
Yes
Yes
Yes
Yes
Ins1
Yes
Yes
N/A
No
Ins2
Yes
Yes
N/A
No
103
About two-thirds of Kansas‟ budget is funded through federal and local
foundation grants. The Kansas State Legislature funds the telemedicine program as a line
item and recently awarded additional money from the tobacco settlement for statewide
fellowships.
16. Does your organization collect data and generate reports on telemedicine activity?
a. What kinds of data are collected?
b.
Who compiles the data and writes the report?
Academic Medical Systems
Arizona has an assistant director for evaluation, a medical statistician, who
compiles the data and writes the reports.
Most of the reporting done by East Carolina Telemedicine has been grant
reporting. Reporting is also required by the university for all its centers and institutes.
Non-Academic Medical Systems
Eastern Montana generates and distributes reports as a way to communicate the
value of the network to its partners. The Telemedicine Director is responsible for
collecting data and writing reports. Data are collected about individual site usage and
how much money is saved in travel costs for network employees or for education.
104
Marshfield Clinic TeleHealth Network generates federal grant reports quarterly
and annually, which are also distributed internally, on utilization statistics and data on
patient and provider satisfaction. Marshfield has also done some time-motion studies
comparing telemedicine or telehealth and traditional medicine, a large clinical outcomes
study in tele-dermatology and plan to do another outcomes study for telemedicine in
long-term care.
State-wide Telemedicine Networks
Kansas Telemedicine collects data on utilization trends, acceptance, and cost
studies. Two research assistants collect data and help with the interpretation and two
health economists are working with the network on cost studies.
Missouri Telehealth collects data on how far patients would have had to travel
without telehealth and/or how long would they have waited for a specialist to travel to
their community.
Insurer-based Systems
Insurer-based One‟s Clinical Research Manager compiles the data and writes
reports. Data collected include utilization, time and distance savings, patient and provider
satisfaction, and transfer of educational information.
Insurer-based Two‟s E-Health Manager is responsible for compiling data and
writing reports, but is able to draw upon organizational resources, such as statisticians, if
needed.
105
17. Does your organization offer any training in telemedicine? If so, for whom and
what kind?
Academic Medical Systems
Arizona Telemedicine conducts multi-faceted training. When a new site comes
on-line, the group has 2 ½ days of training involving six or eight persons: the CEO,
Medical Director, Telemedicine Director, Telemedicine Coordinator, a technical person,
and any physicians involved. As a follow-up, the hub site telemedicine coordinator and
technology coordinator are sent to the spoke site for training. This takes place within a
couple of weeks of the on-site training. The network also offers one-day training for
Legislators, the Arizona Telemedicine Council, and others, as appropriate, and two-hour
training sessions for an overview demonstration. Arizona also conducts an annual
Telemedicine Corrections Conference, the last of which, the 3rd Annual Corrections
Conference, was attended by 235 with 30 vendors.
East Carolina Telemedicine has a large telemedicine training center that trains
people from across the United States and other countries. No, we‟ve had people from all
over the United States and other countries. The week-long training sessions allow people
to spend some time with the equipment and go through a training series depending on the
area of interest, whether technical, clinical, or administrative. Revenue from the training
program is part of the operational budget.
106
Non-Academic Medical Systems
Eastern Montana TeleMedicine Network conducts significant training for
telemedicine facilitators at new sites and annual training sessions at the Deaconess
Billings Clinic hub site for all the site telemedicine facilitators together. Additional
training and communication is done over interactive video and the director meets bimonthly with the site facilitators to address training and operational issues.
Marshfield Clinic TeleHealth Program Manager trains telehealth nurses who then
train other staff in regional centers using video-conferencing. The Program Manager also
supervises telehealth training of nursing home staff and all the home health staff to
present patients in a way that recreates the human interaction of the clinical consult. New
employees receive two weeks of orientation in telehealth, then one or two full clinic days
with each of the specialty providers. And then about once about every two months, the
telehealth employees spend a few days with a specialty provider. The telehealth program
manager also sits in on the first telehealth encounters with new specialty providers to
provide needed coaching or training, and provides training to their staff in
documentation, billing and coding.
State-wide Telemedicine Networks
Kansas University Center for TeleMedicine and TeleHealth trains school nurses
for its largest program, TeleKid Care®, with two-day training sessions at the hub site.
107
KUCTT has a training curriculum for new specialty consultants that includes practice
with peripheral telemedicine equipment, such as a tele-stethoscope or tele-otoscope.
Missouri Telehealth Network trains end users how to use the equipment. Upon
installation of a new site, training personnel are sent two, three, or four times, whatever is
needed to be sure that the staff is trained on how to use all the equipment. The EMS
(emergency medical service) training staff and the neo-natal transport staff use the
network to train personnel at the rural spoke sites.
Insurer-based Systems
The Clinical Research Manager of the Insurer-based One‟s Demonstration Project
wrote a training manual, an operations manual and a training program that was delivered
on site throughout the entire network.
Insurer-based Two‟s telemedicine training is conducted by whoever is running the
project, usually the project manager. For instance, the Tele-Homecare Project Manager
hired a nurse educator who received training from the vendor and then in turn trained the
staff on how to use the equipment. In addition, in-service training is a continuing process
within the system.
18. Does your organization market or publicize telemedicine to healthcare
consumers? … to healthcare professionals? If so, what kind?
Academic Medical Systems
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Arizona Telemedicine has an extensive Web site,
http://www.telemedicine.arizona.edu/, and produces brochures that are sent to the
legislature and to healthcare professionals throughout the state. Telemedicine personnel
give talks in response to frequent requests for speakers and the Public Relations
Department at the university sends out press releases to local television and newspapers.
East Carolina Telemedicine also has an extensive Web site,
http://www.telemed.med.ecu.edu/, and publishes a newsletter that is sent out to all
interested parties. Numerous television and news articles have featured East Carolina
Telemedicine and the university Public Relations Department sends out press releases
about telemedicine events or grant awards.
Non-academic Medical Systems
Eastern Montana Telemedicine Network, www.emtn.org. markets to both
healthcare providers and consumers. EMTN educates, very heavily internally, to new
physicians and new employees. The network sponsors frequent organizational activities
that highlight telemedicine, such as open houses during TeleHealth Month. Externally, it
publishes a Web site, a quarterly newsletter for healthcare providers throughout the
region, and frequent articles about the telemedicine network in local newspapers. Eastern
Montana is an active partner in the Montana Healthcare Telecommunication Alliance, an
alliance of all the telemedicine networks throughout Montana that advocate for
telemedicine throughout the state.
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Although Marshfield Clinic TeleHealth has no official Web site, news stories
about the telehealth network are posted on the parent organizations‟s Web site at
http://www.marshfieldclinic.org/ . The telehealth network takes every opportunity to
market internally through staff meetings and externally through community outreach
activities. New programs, grants, and milestones are publicized through print and
broadcast media.
State-wide Telemedicine Networks
Kansas Telemedicine does not advertise externally, except for the Web site at
telemedicine@kumc.edu, because that may be seen as competing with private
practitioners. The network does publish program successes in internal papers and work
with the Public Relations Department of the university for press releases.
Missouri Telehealth publishes a Web site, http://www.telehealth.muhealth.org,
and a brochure. The network does not market per se on TV or newspaper, but market
informally to healthcare professionals through in-person visits.
Insurer-based Systems
Neither insurer-based system advertises its telemedicine program per se, but their
public relations departments issue press releases and arrange requested interviews.
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Insurer-based Two‟s tele-homecare and e-health have been featured in multiple
medical journals, newspapers, and television programs: the New York Times, the Post,
Chicago Tribune, NBC News, MSNBC, Fox News Network.
Evaluation Questions
19. What do you consider the greatest barriers to the growth of telemedicine in your
organization?
20. What efforts has your organization made (if any) to overcome those barriers?
Academic Medical Systems
Arizona Telemedicine Program
The key informant from Arizona Telemedicine lists three major barriers to the
growth of telemedicine: (1) the cost of telecommunications lines (the Universal Services
program helps with this, but there is no telecommunications infrastructure in the state);
2) physician participation (over 90 physicians participate): and 3) profitability and/or
sustainability.
Arizona Telemedicine‟s efforts to overcome barriers to growth include 1) site
surveys to assess needs; 2) the purchase from department heads of ½ day clinic time to
pay physicians to work an afternoon; 3) the establishment of Project Nightingale to
design and implement the telecommunications infrastructure necessary to
connect healthcare sites to the Arizona Telemedicine Program. Additionally, the Arizona
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Telemedicine Council was established when the state legislature funded the program.
The council includes such key people as the head of appropriations from the State House
and Senate, representatives from government, universities, Mayo Clinic, and other key
people in healthcare, corrections, telecommunications and government. The
Telemedicine Council meets quarterly and are given progress reports
East Carolina Telemedicine Program.
East Carolina Telemedicine‟s key informant thinks that limited insurance
reimbursement is a barrier. The availability of consultants is probably limited by the
desire to market telemedicine. Convenience to the consultants is an issue that the key
informant would like to address by having inter-office network tele-communications,
although some of the sites are connected too simply to allow for interactive audio and
video.
East Carolina‟s key informant noted that the attitudes of referring providers is the
area that requires the most work, is the most time-consuming and the least rewarding for
the amount of time spent. ECU Telemedicine found that primary physicians will not refer
patients to specialists using telemedicine unless they are already part of his or her referral
pattern.
Efforts to overcome barriers to growth include promoting telemedicine with
events such as breakfasts. When a new site comes on, some of the telemedicine staff are
sent to discuss problems and what the program has to offer.
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Telemedicine is also marketed to new faculty members who are brought in to
“test drive” telemedicine equipment and do mock consults with a rural site to become
comfortable with the technology.
Telemedicine staff has also been working on reimbursements, to make it more
convenient for providers. Another convenience for providers has been to offer Store-andForward technology for dermatology.
Non-academic Medical Systems
Eastern Montana Telemedicine Network
Eastern Montana Telemedicine‟s key informant claims the greatest barriers are
assisting providers in understanding value and facilitating change in the way they practice
medicine. Among physicians, the key informant notes, it is generally in their character, a
need to see clear benefits for new and different ways of doing things to be accepted.
So the barrier is not so much resistance to change as it is physicians knowing how to use
this technology to make their practices more efficient and to improve quality.
Efforts to overcome barriers to growth include the formation of a telemedicine
advisory group, in which each member of the consortium assists in oversight of the
telemedicine network. Members of the consortium include two members from each
facility that has telemedicine equipment, usually the site administrator and site
telemedicine facilitator plus representatives from each of the telecom carriers,
representatives from local higher education, and urban and rural physicians.
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Every physician affiliated with Deaconess Billings Clinic, the telemedicine hub site,
is obligated to help with the telemedicine program, if needed, for specialty consults and
each new physician undergoes a telemedicine orientation process.
Marshfield Clinic TeleHealth Network.
Marshfield Clinic‟s key informant believes that the greatest barrier to telehealth is
a shortage of specialty providers. A second barrier is that some people do not understand
telehealth and its importance to providers and patients in rural areas. Sometimes, because
of lack of communication, program expansion is limited because people do not
understand that it is possible to do it.
Marshfield Clinic TeleHealth‟s key informant believes that when the technology
works for them, physicians love it. An example is cited of a child psychiatrist who
adopted it immediately. After using it just once, he went back to his practice, had his
office staff look through his patient files, find out where they lived and how they could
get to the closest video conferencing center or telehealth center.
The key informant also identifies the clinic‟s medical director as a “real
champion” of telehealth, which is an important element in promoting telehealth use and
acceptance within the organization.
State-wide Telemedicine Networks
Kansas University Center for TeleMedicine and TeleHealth
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Kansas Telemedicine‟s key informant cited funding and space constraints at
Kansas as major barriers to the growth of telemedicine locally. While KY has the
infrastructure to support more activity, to be able to go to the next phase of greater
activity will require more technical support personnel and more physical space for the
telemedicine department. Nationally, the key informant believes that the greatest barrier
to telemedicine growth nationally is adoption by providers, not acceptance by patients or
reimbursement or licensure.
The key informant cites building personal relationships with healthcare providers
as an important factor in recruiting healthcare specialists to use telemedicine. The key
informant also believes a contractural relationship and the process of setting up a
specialty telemedicine service for a specified fee, such as contracting with pediatric
cardiology to set up a pediatric cardiology telemedicine service with teleechocardiography, eliminates provider resistance.
Missouri Telehealth Network
The Missouri Telehealth key informant stated that the cost of phone lines, T-1
type lines, and lack of Medicaid reimbursement were the greatest barriers to telemedicine
growth. When asked whether MTN has any problems getting providers or referrals from
rural areas, the key informant responded that was probably not so much a barrier, as it is
trying to continually cultivate relationships between referring physicians and specialty
healthcare providers who use telemedicine. The technology is secondary to the persons
providing the healthcare services.
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Missouri Telehealth‟s key informant cites Medicare reimbursement as a barrier to
telemedicine growth that has been overcome by a cooperative effort of a team of
telemedicine leaders from across the country who worked on drafting the legislative
language then working to see it push through the U.S. House and Senate.
In a similar effort, Missouri Telehealth is working with others organizations, such
as the Public Service Commission and phone companies, in trying to find ways to get an
affordable tariff established for T-1 lines.
To get the word out about telemedicine, Missouri Telehealth has established
community advisory groups that meet quarterly. The advisory groups are comprised of
medical personnel and representation from schools, business, industry, public health, and
university extension. Updates on the telehealth network are presented and input is
solicited about community healthcare needs.
Insurer-based Systems
Insurer-based One Telemedicine Demonstration Project
Insurer-based One‟s key informant lists organizational politics, concerns about the
effect on healthcare quality, and the corporate bottom line as the greatest barriers to
telemedicine growth.
The key informant cites internal research reports documenting high patient
satisfaction rates and cost-effectiveness of telemedicine as an effective response to
organizational barriers.
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Insurer-based Two E-Health
Insurer-based Two‟s key informant cites resistance to change as a major barrier to
the growth to telehealth, particularly by the financial decision-makers who want a
guarantee of profitability.
The key informant names project managers who are champions for their
telehealth projects and are enthusiastic mentors of the project within the organization as
the greatest resource to overcome barriers to growth.
21. Which telemedicine applications do you consider the most successful in your
organization?
22. What factors do you think have contributed to the success of these applications?
23. What do you define as success in your TM program?
Academic Medical Systems
Arizona Telemedicine Program
Arizona Telemedicine‟s key informant lists prison telemedicine, the Indian Health
Service, distance education, and clinical telemedicine as their most successful
telemedicine applications.
Factors contributing to the success of these applications include telemedicine
champions and visionaries within the organization. Another factor cited by the key
informant is that the network has been able to retain experienced and energetic staff.
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Success is measured by the improvement to the quality of life of the people of Arizona.
East Carolina University Telemedicine Program
The key informant from East Carolina Telemedicine lists tele-dermatology as
clearly the most successful, followed by tele-rehabilitation and pediatric medicine,
particularly at one of the spoke sites, School for the Deaf.
The success of telemedicine‟s clinical operations is explained by the key
informant as the result of the real need for greater access to specialty care together with
the enthusiasm of the healthcare providers who are champions and advocates for
telemedicine.
The key informant believes that utilization is the major indicator of success. Once
a telemedicine service is sufficiently utilized, further research can be done, such as costbenefit analysis and hospitalization rates.
Non-academic Medical Systems
Eastern Montana Telemedicine Network‟s key informant lists psychiatry, clinical
education, and continuing medical education (CME) as its three most successful
telemedicine applications.
The factors contributing to these successes were listed as meeting demand and
need. There are no psychiatrists east of Billings, Montana and there would be great
difficulty earning continuing medical credits without the telemedicine network because of
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great distances between sites – the closest telemedicine site is 120 miles away and the
farthest is more than 300 miles from the hub site.
The key informant for Eastern Montana Telemedicine defines success as having
partners who believe that the network is meeting their needs and consortium members see
enough value in the network to pay the price to be a part of the network.
Marshfield Clinic TeleHealth Network
Marshfield Clinic TeleHealth‟s key informant lists cardiology, occupational
medicine, psychiatry, and nutritional services as its most successful applications.
The key informant also cites burn management as a great success because of its impact,
not because of the large number of patients. A burn patient can get excellent care in a
local facility with local staff and the patient‟s own primary physician working
cooperatively with a plastic surgeon via the telehealth network.
The factors most critical to the success of telehealth are the telehealth nurse
clinicians and the role that they play. The nurses present the patient, act as patient
advocates and work with referring providers to facilitate both communication and the
patient-consulting provider relationship. Another factor is specialty physicians who are
champions of telehealth within their respective specialties.
The key informant defined success as the patient having unrestricted access to
appropriate care at the appropriate time, with the appropriate provider; that the consulting
and primary care providers have a direct relationship that is enhanced with telehealth; and
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that the patients have their clinical needs met, while feeling comfortable and safe in their
local environment.
State-wide Telemedicine Networks
Kansas Center for TeleMedicine and TeleHealth‟s key informant lists schoolbased telemedicine, tele-psychology, and tele-oncology as its most successful
applications.
The most important factor responsible for the successes of the program is having
a champion for telemedicine who “runs with it,” who has a vision, and who is willing to
take a chance. Kansas Telemedicine‟s key informant believes that makes all the
difference.
Success for telemedicine is defined by the key informant as longevity, ongoing
relationships, true health care delivery teams, and the amount of utilization, although
numbers alone are not as important as increasing access to healthcare in rural areas,
especially sparsely populated rural areas.
Missouri Telehealth Network
Missouri Telehealth‟s key informant maintains that psychiatry and dermatology
are the network‟s most successful applications.
The reason given for the success of these applications is a defined, pent-up need:
a lack of mental healthcare and dermatologists throughout the state.
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The key informant defined success as utilization of the telehealth network and as
the provision of telehealthcare services that are otherwise nonexistent in many rural
communities.
Insurer-based Systems
Insurer-based One Telemedicine Demonstration Project has only one set of
applications – interactive primary care. Research indicates that the project is costeffective and has a high satisfaction rate with telemedicine for both patients and
providers.
The key informant for Insurer-based One Telemedicine defined a successful
program as one that serves its stated purposes and is sustainable.
The key informant for Insurer-based Two cites radiology as the most successful
telemedicine application because it affects so many and the data are used for diagnosis
and treatment. So much radiological film has been digitized and read that the collection
has become a valuable archival teaching and diagnostic tool that doctors routinely consult
for unusual cases.
Factors that have contributed to the success of the telemedicine program include
passion for the work and the belief that the program was going to increase access to
quality care for people.
The key informant defined success of the program from the patient‟s point of
view. Success is when patients feel empowered, when they feel they have a sense of
control about their healthcare and feel confident about telemedicine.
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24. What future applications for telemedicine do you think would be successful in your
organization?
25. If you could change anything about telemedicine in your organization, what would
it be?
Academic Medical Systems
Arizona Telemedicine Program
Future applications for Arizona Telemedicine include school health and
expansion of telemedicine in Panama, which already has four spoke sites.
The key informant could not think of any changes to the telemedicine program
because it already enjoys tremendous support.
East Carolina Telemedicine Program
Applications that the key informant thinks will be successful in the future include
homecare for high-risk pregnancies, neo-natal patients, congestive heart failure patients,
rehabilitation patients who are difficult to mobilize, and other traumatic brain injury
patients. Rehabilitation is clearly an area for expansion, as is the Next Generation
Internet Project and a project in which digital electromyography (EMG) and nerve
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conductions are done locally by technicians and sent to ECU for reference study and
interpretation.
One thing that ECU is working on changing is integrating telemedicine more into
operations, particularly integrating it more into the mainstream of the clinical
applications, so that it‟s not just a telemedicine program, but a practice and clinical
operations in the medical school. The key informant also expressed a desire for more
financial support from university leadership and more recognition for technical
telemedicine personnel who have company credentials that do not fit well in an academic
system.
Non-Academic Medical Systems
Eastern Montana Telemedicine Network
Short-term plans for Eastern Montana Telemedicine‟s future include a Neonatal
Intensive Care Unit (NICU) project using POTS (plain old telephone system) video, in
which video-phones will be sent home with new moms if their babies have to stay in
NICU, so that mom can see her baby and connect with her baby from home. A cardiology
clinic will soon be connected to the telemedicine network, and if that and cardiovascular
surgery follow-ups are successful, those services will be expanded. Still in the planning
stages are tele-homecare and occupational medicine, which will support contracts that are
being developed throughout the region. Another planned area of expansion is diabetes
education, with plans to have Deaconess Billings Clinic‟s Certified Diabetes Educator
(CDE) and nutritionist use the telemedicine network to train nurses and dieticians
throughout the region to be providers of these services to their local areas.
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One of the things that the organization has done internally is to implement a
picture archives and communication (PAC) system, a digital, filmless radiology system.
EMTN is pushing that technology out to the regional partners, along with digital patient
information software, which will improve communications between the specialty
consulting physicians, referring physicians and their patients.
Long-term plans, in the next 3-5 years, are to have a clinical work station in every
specialty area that is appropriate for telemedicine within the organization, and eventually
a T-3 environment over the system‟s LAN that can integrate more data.
The only things that the key informant would change would be to have more
funding and/or lower telecommunications costs. The network receives incredible support
both within the organization and throughout the region and it has an experienced group of
site facilitators who have been with the network from the beginning.
Marshfield Clinic TeleHealth Network
The key informant defines future successful applications of telehealth at
Marshfield Clinic as any opportunity to have physicians and other health professionals
spend more time doing what they were trained to do instead of traveling. The future of
telehealth in the region is to extend the scope and services of telehealth at Marshfield
Clinic.
The key informant does not see any needed changes because the program was set
up with the patient and the provider as the central focus. The telehealth network was
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built in such as way as to make the relationship between the provider and the patient the
most important element.
State-wide Telemedicine Networks
Kansas Center for TeleMedicine and TeleHealth
Kansas Telemedicine‟s key informant would like to see occupational telehealth in
the future, as well as a stronger home health presence and patient healthcare tutorials. In
addition, transitional medical care from the in-patient setting to the outpatient setting, in
which the doctor is part of that transition, would allow earlier discharge of some patients.
What the key informant would change would be an integration of outreach
services in the state, such as the Office of Rural Health, Office of Health Education
Centers, Continuing Medical Education Office, and, of course, the Center for
TeleMedicine and TeleHealth. Currently there is no cooperation or coordination of
outreach services among these offices that perform very similar functions statewide.
Missouri Telehealth Network
Future applications that would be successful at Missouri Telehealth, according to
the key informant, would include Workers‟ Compensation cases and occupational
medicine. A local clinic or hospital connected to specialists via the telehealth network
would save an employer both time and money for his injured employee. Large
corporations with their own clinics may even become a spoke site in the telehealth
network.
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Telehealth in public schools is another application that is in the planning stage.
Missouri Telehealth Network is teaming with MORNET, the Missouri Research and
Educational Network, to install T-1 lines to all of the spoke sites in the network.
MORNET‟s mandate from the state of Missouri is to connect schools and libraries, and
sharing that infrastructure helps in reducing telehealth costs as well as opening up the
schools and libraries to the network. The school project will be funded by state tobacco
settlement money.
Insurer-based Systems
Insurer-based One Telemedicine Demonstration Project
Insurer-based One Telemedicine‟s key informant believes that the demonstration
project will continue to be successful and will only grow as long as it manages resources
efficiently and provides needed services.
Changes that the key informant would make would include making telemedicine a
separate department and fully funding it.
Insurer-based Two E-Health
Insurer-based Two‟s key informant believes that disease management and
preventative healthcare will be the most successful future applications.
Suggested organizational changes include a corporate environment that is more
open and embracing to new technologies and having a greater emphasis on increasing
quality and access to healthcare.
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CHAPTER V
DISCUSSION
Introduction
Analysis of the key informants‟ interviews, publications, and grant progress
reports was used to determine whether any structural commonalities exist in the
telemedicine programs across these different types of organizations to determine whether
any unique features exist in the telemedicine programs within each type of organization.
While there are some minor structural differences in telemedicine programs
among the different types of organizations in this study and there are many more
commonalities.
Research Question One
What is the organizational structure of an academic institution/school of medicine
telemedicine network versus a non-academic institution/school of medicine
telemedicine network versus a statewide telemedicine network versus an insurer-run
telemedicine network? What is the hierarchical structure, funding sources, type and
level of staffing?
In some instances organizational structure may be reflected by the name of the
organization. There are some name similarities within three of the four types of
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telemedicine/telehealth organizations. Both of the academic medical center cases are
identified as telemedicine programs. The two non-academic medical center cases are
identified as networks: one a telemedicine network and the other a telehealth network.
The two statewide systems are identified by the term telehealth: one, a center for
telemedicine and telehealth; and the other, a telehealth network. The two insurer-based
cases have no terms in common. One is identified as a telemedicine demonstration
project and the other as “e-health.”
In both academic medical centers, the telemedicine program is located within the
medical school, Arizona within the Department of Pathology (Appendix 4A) and East
Carolina within the Department of Health Communications (Appendix 5).
Both non-academic-based systems, Eastern Montana Telemedicine Network
(Appendix 6) and Marshfield Clinic TeleHealth Network, are integrated within an
organization of health clinics: Montana under Marketing and Marshfield under ProActive Health Services.
Both statewide networks are headquartered within their state university medical
schools: Kansas within the Department of Information Technology (Appendix 7A) and
Missouri within the Department of External Affairs (Appendix 8).
All of the telemedicine programs in this study are funded by multiple and diverse
sources. All receive grant funding as well as internal support. The two insurer-based
programs are funded by state grants. The others are funded by federal grants, primarily
from OAT, the Office for the Advancement of Telehealth. All non-insurer-based systems
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receive insurance reimbursement. The two state-wide telemedicine networks, as well as
one of the academic medical systems, Arizona, receive state line-item funding.
Other sources of funding include network membership fees from the network
spoke sites (East Carolina and Eastern Montana) and income from a telemedicine training
program (East Carolina).
All of the telemedicine programs, with the exception of the two insurer-based
programs that declined to answer, employ a combination of both full-time and part-time
staff. Four of the six programs have only three or four full-time employees and four
programs have two to four part-time employees.
A statewide system seems to be a particularly efficient way to develop a
telemedicine network, particularly within a pre-existing statewide medical system. A
combination of state funding and federal grants with local in-house organizational
support insures funding for sustainability and growth of the network. Additional services
provided through the network, such as in-house training, CME courses, or public health
education, add value to network membership and may provide an additional source of
revenue for the network.
Telemedicine or telehealth is typically a separate department within the
organization, logically located within another, larger department with technology
resources, such as radiology, health communications, or patient outreach services.
All of the programs in this study employ a combination of full-time and part-time
staff, typically a core of three or four full-time employees and several part-time
employees.
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Research Question Two
What kinds of human resources are necessary, and what roles must they play? What
capabilities are necessary?
While the academic-based telemedicine programs, Arizona and ECU, appear to
have an opposite configuration (Arizona, four FTEs, eighteen PTEs; ECU seventeen
FTEs, two PTEs), they have some elements in common. Both employ a director, an
associate director, a distance education coordinator, project manager/director,
telemedicine coordinators, administrative assistant(s), and telemedicine technicians.
Arizona‟s employee structure appears to be more integrated and flexible, while ECU‟s
focus is oriented toward large projects, such as its telemedicine training program and an
NLM Next Generation Internet Project.
The two non-academic-based programs, Eastern Montana Telemedicine and
Marshfield Clinic TeleHealth, are similarly integrated into their clinic-based systems.
Each program supports a full-time director/manager. Additionally, grant funding supports
two telemedicine technicians and a telemedicine registered nurse at Montana and two
clinicians at Marshfield. Each of the fifteen Montana spoke sites supports a .5 FTE. Parttime employees at Marshfield Clinic TeleHealth include a medical director, an
administrative director, information services personnel and a scheduler.
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Kansas employs thirteen full-time employees, including four project managers, a
project coordinator, two video technicians, and a media production manager. Two parttime employees are research assistants.
Missouri full-time employees include an executive director, an assistant director,
an administrative associate and an administrative assistant. Four part-time employees
include a coordinator of program and project support, a continuing education coordinator,
a network support specialist, and a user support analyst.
Employee roles and capabilities seem to fall into several categories:
1) Administrative, including a director/manager, assistant(s), scheduler(s)
2) Clinical/medical, including medical director, project manager(s),
coordinator(s), telemedicine nurse(s)
3) Research, including data collector(s), evaluator(s)
4) Technical support, such as telemedicine engineer(s), technician(s)
Another possible category, education, may include distance education
coordinator(s) and assistant(s) and/or telemedicine training coordinator(s) and
assistant(s).
In half the organizations in this study, physician specialists are actively involved
in developing and overseeing the telemedicine program. Direct involvement of medical
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specialists seems to be an important factor in recruiting their colleagues, other specialty
physicians, to participate in telemedicine.
Another important telemedicine healthcare professional is a registered nurse. All
of the programs in this study employed at least one (and usually more than one)
telemedicine RN, who performs a variety of duties from training to coordinating specific
projects.
A technical support specialist is another vital member of the telemedicine team.
Engineers and/or technicians insure the smooth operation of the telecommunications
infrastructure and equipment, the conduit over which the telemedicine network operates.
Other important support personnel for the telemedicine team may include
administrative assistants and/or schedulers, evaluation researchers and grant-writing
specialists.
Research Question Three
What are the organizational problems and barriers of building, maintaining, and
sustaining a telemedicine network?
According to the key informants, the major barriers to building, maintaining and
sustaining a telemedicine network are:
1. The cost of telecommunications lines and lack of telecommunications
infrastructure
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2. Physician participation, both referring and providing
3. Concerns about costs and profitability of the telemedicine network; concerns
about limited insurance reimbursement for telehealth services
4. Internal support, organizational politics, lack of understanding, lack of
champions, resistance to change
Telemedicine is becoming increasingly accepted by insurance companies as a
cost-effective healthcare delivery system. The major remaining barriers of developing
and sustaining a telemedicine network fall into two main categories: lack of
telecommunication infrastructure or prohibitive cost of using existing infrastructure and
reluctance to adopt and support telehealth and telemedicine by healthcare provider
administrators and physicians.
Research Question Four
What organizational structure is most conducive for success in a telemedicine
network? Success can be defined as sustainability, full use, increased access and
diversity of services offered. The definition of success will be determined by the key
informants of a particular telemedicine network.
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According to the key informants, organizational factors that overcome barriers
and influence success and sustainability of a telemedicine program include:
1. Development and implementation of telecommunications infrastructure, what
Puskin calls a “televillage”152
2. Multiple uses of telemedicine network for telehealth, telemedicine, distance
education, and community service and development
3. Formation of an advisory oversight group of key players to identify healthcare
needs and to assist in devising and funding network strategies to address those
needs.
4. Movement toward integration of telemedicine into departments and physician
desktop environments
5. Development and strengthening of relationships between referring and providing
physicians and between healthcare providers and consumers.
6. Multiple and diverse sources of funding
7. Support and marketing including in-service training and promotion of telehealth
and telemedicine services and external consumer marketing.
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Specific Organizational Initiatives
According to the key informants, organizations in this study developed some
specific initiatives to help their telemedicine or telehealth program overcome barriers to
growth and sustainability.
1. Development and implementation of telecommunications infrastructure for
multiple uses (telehealth, telemedicine, and distance education)
The prospects for sustainable rural telemedicine systems improve
when we can use the technology to address a community‟s broader health
information needs through multi-use systems. However, experience also
suggests that there are many logistical challenges to building these systems. 153
While the Universal Services Program helps somewhat with funding,
telecommunication costs were specifically listed as a concern for Arizona, East Carolina,
Montana, and Missouri.
Arizona, concerned about the lack of telecommunications infrastructure in the
state, established Project Nightingale to design and implement the infrastructure
necessary to connect healthcare sites to its telemedicine network. The network is a
Dena S. Puskin, Carole L. Mintzer, and Cathy J Wasem, “Telemedicine: Building Rural Systems for
Today and Tomorrow,” Information Networks for Community Health, Patricia Flatley et al., eds. New
York: Springer, 1997, 274, 276.
152
153
Ibid., 271.
Dena S. Puskin, “Opportunities and Challenges to Telemedicine in Rural America,” Journal of Medical
Systems 19 (1995), 59.
135
member of the Arizona Telecommunications System (ATS), a state effort to enhance
telecommunications infrastructure.
Missouri Telehealth is working with the Public Service Commission, phone
companies, and other interested parties to find ways to obtain a more affordable tariff for
T-1 lines for telehealth and telemedicine networks. Missouri Telehealth is also teaming
up with MORNET, the Missouri Research and Educational Network, that connects
schools and libraries, to share infrastructure resources.
2. Multiple uses of telemedicine network for telehealth, telemedicine, distance
education, and community service and development.
In addition to offering clinical services, all of the eight organizations offer some
types of educational services. Arizona offers CME (continuing medical education)
courses for pharmacists, physicians, and nurses. ECU offers education for public health
nurses over the network, while the Kansas network offers community-based public
educational series on topics such as diabetes, fibromyalgia, and smoking cessation. .
Eastern Montana offers CME courses, public health education, diabetes
education, and precepts (advises) family practice residents in rural areas. The network
also has a unit in the local office of the Montana Hospital Association so that members of
the network may “virtually” attend association meetings without long-distance travel.
136
Missouri Telehealth offers CME courses and has two area health education
centers where third year residents are precepted or advised by overseeing physicians.
Marshfield Clinic uses its network for an internal employee assistance counseling service.
3. Formation of an advisory oversight group of key players to identify healthcare
needs and to assist in devising and funding network strategies to address those
needs.
The Arizona Telemedicine Council was established with key members of the state
legislature and other key people in healthcare, and telecommunications to report progress
and areas of need for future development.
Eastern Montana formed a telemedicine advisory group to oversee the network.
The advisory group is composed of two members from each telemedicine network site,
usually the administrator and site facilitator, plus representatives from all of the telecom
carriers, representatives from local higher education, and urban and rural physicians.
EMTN is a member of the Montana Healthcare Telecommunication Alliance, an
organization that advocates for telemedicine throughout the state. EMTN publishes a
quarterly newsletter that is distributed to healthcare providers throughout the region.
Missouri Telehealth established community advisory groups, composed of
medical personnel and representatives from schools, business, industry, public health, and
university extension services, to present progress reports and solicit input about
137
community healthcare needs. In addition, the network in working toward the
development of a state telehealth advisory group
4. Movement toward integration of telemedicine into departments and physician
desktop environments.
East Carolina University is working to make telemedicine more integrated and
convenient to providers by offering store-and-forward technology to dermatologists and
by developing an Internet II pilot project.
Eastern Montana Telemedicine‟s goal in the next few years is to have a clinical
work station in every specialty area that is appropriate for telemedicine within the
organization. The network has already implemented a PAC (picture archive and
communication) filmless radiological system as part of a large, integrated organizational
information technology strategy that will improve the ability to communicate with
referring physicians and their patients.
E-mail is an increasing important element in two of the networks. Marshfield
Clinic is experimenting with sending digital dermatology pictures as e-mail attachments
so that the doctor can review those at will in a convenient and timely fashion. Missouri
Telehealth ensures that Internet and e-mail services are functioning at each site in the
network to enhance communications between network members.
138
5. Development and strengthening of relationships between referring and providing
physicians and between healthcare providers and consumers.
Arizona Telemedicine purchases ½ day clinic times from University Medical
Center departments to furnish physicians in a needed specialty to work afternoons for the
telemedicine network. The network conducts site surveys to assess community needs.
The Arizona program is multi-cultural – it has outreach services to increase access to
healthcare services in Native American and Hispanic communities.
East Carolina markets telemedicine both internally and externally. New ECU
Medical Center faculty members are given an orientation “test drive” of the equipment.
The new providers do mock telemedicine consultations with rural sites. The
administration expects medical faculty to use telemedicine as a part of their faculty
responsibilities. ECU Telemedicine team members attend community outreach events,
routinely visit new spoke sites, and publish a regional newsletter.
Eastern Montana, as well as Marshfield Clinic, requires physician participation in
telemedicine as part of their association with the clinics, and both compile and distribute
progress reports as a way of communicating the value of network membership.
The Kansas key informant believes in contracting for a specialty telemedicine
service for a fee, such as contracting with pediatric cardiology to set up a pediatric
cardiology telemedicine service. This practice greatly reduces or eliminates provider
resistance.
139
6. Multiple and diverse sources of funding.
East Carolina Telemedicine generates extra funding for its program with a large
international telemedicine training program. ECU also generates funding by charging a
network membership fee.
Eastern Montana also charges a fee for network membership and, additionally,
each member is required to furnish a .5 employee dedicated to the telemedicine network.
EMTN sells network time to non-healthcare providers (individuals, groups, or
businesses). Recently, a couple leased network time for a long-distance consultation with
an architect.
Arizona, Kansas, and Missouri are funded by their states. Each also has federal
grant funding. Both Kansas and Missouri are funded in part by state tobacco settlement
funds, which will be used to expand their programs.
7. Internal support, including training and promotion of telehealth and telemedicine
services.
Arizona offers multi-faceted training. When a new site comes on-line, a group of
six to eight persons, usually the CEO, Medical Director, Telemedicine Director,
Telemedicine Coordinator, a technical person, and physicians, receives two days of
training at the Telemedicine Training Center at Tucson. A follow-up case manager and
coordinator are sent to the spoke site for training within a couple of weeks. Legislators
140
and the Telemedicine Council have a one-day training session, and two orientation and
demonstration sessions are available. Arizona also hosts an annual Corrections
Conference, which breaks even financially.
New faculty members at ECU Medical Center are routinely oriented to
telemedicine by conducting mock consultations with rural sites to become comfortable
with the technology.
Comments
Several of these initiatives seem particularly useful in developing, sustaining, and
growing telemedicine networks. Statewide telecommunications infrastructure with
cooperative networks, including schools and libraries as well as hospitals and clinics,
could reduce costs and maximize usefulness.
Complementing and supporting the infrastructure initiative, an advisory group
may consist of key players, such as state legislators; medical professionals and
administrators; representatives from the telecommunications industry, higher education
and professional healthcare education; and representatives from the telemedicine
network.
Advisory groups serve three important functions. First, they can be instrumental
in assessing statewide needs and in recommending development of network programs
and services to address those needs. Second, key players from state government and the
telecommunications industry may play key roles in supporting the development of a cost141
effective network infrastructure. Third, the inclusion of healthcare professionals,
particularly healthcare educators and administrators, could promote the adoption and
integration of telemedicine within the state‟s community of healthcare providers.
Marketing strategies could play an important role in expanding telemedicine and
telehealth networks. Internal training and marketing of telemedicine promote the
adoption of telehealth technologies and use of the network by healthcare professionals.
Effective external marketing strategies may increase utilization of a telehealth network
“by making consumers aware of the telehealth system‟s ability to deliver quick,
convenient and comfortable access.”154 Strategic marketing could increase public
demand for telehealth services, which could also fuel provider acceptance and adoption.
Telemedicine Theory
Cybernetic Model
Cramp and Carson‟ cybernetic healthcare model
155
may be modified to
reflect more specifically a telehealth system. Figure 22 illustrates a simplified conceptual
model of telehealth dynamics.
154
Susan L. Dimmick and Samuel G. Burgiss, "Marketing Strategies for Telehealth Programs." In
Telecommunications for Nurses: Providing Successful Distance Education & Telehealth, 2nd Edition, M.L.
Armstrong and S. Frueh, eds. New York: Springer Publishing, 2002.
Derek G. Cramp and Ewart R. Carson, “A Model-Based Framework for Public Health: A Vehicle for
Maximising the Value of Telecare?” S Laxminarayan, ed., Proceedings of the 3rd IEEE EMBS
International Conference on Information Technology Applications in Biomedicine (ITAB 2000),
Piscataway, NJ: IEEE, 2000, 272-277.
155
142
Cramp and Carson’s Simplified Conceptual Healthcare Model156
Figure 22.
Simplified Conceptual Telehealth Model
A Modification of Cramp and Carson’s Simplified Conceptual Healthcare Model157
156
Crook and Carson, 275.
157
Ibid..
143
Three of the main components of the model are telehealth management (decisionmakers), telehealth service provision, and the target population, with telecommunications
systems and infrastructure supporting management and providing a feedback loop. This
feedback loop is particularly important in the telehealth model because “healthcare
practiced from a distance” is completely dependent on the underlying
telecommunications systems and infrastructure.
Diffusion of Telemedicine
Mapping the results of this study to the Diffusion of Innovations Model illustrates
some of the conditions that affect adoption and diffusion of telemedicine.
While none of the key informants used Roger‟s term of opinion leaders, they all
mentioned the importance of the committed, influential individuals within their
organizations with such descriptive terms as champions or cheerleaders of telemedicine.
“Compatibility with values and needs of adopters,” “perceived complexity of
use,” “trialability and observability” are some of Roger‟s innovation characteristics that
were not expressed verbatim, but were alluded to by the key informants‟ emphasis on the
importance of making telemedicine convenient for the physicians and of making
telemedicine visible through marketing and training. Some of the key informants‟
organizations require or encourage new physicians to do a “trial run” or “test drive” the
equipment to increase familiarity and comfort levels.
144
The other characteristic of innovation adoption, “perceived relative advantage,”
identifies the problem that telemedicine has in becoming more widespread within the
general population of healthcare providers. Telemedicine is a patient-centered
technology, delivering healthcare services to the patient, either in the home or in a local,
more convenient facility. Telemedicine has little perceived relative advantage for
physicians and other healthcare providers who are accustomed to having patients come to
them. Early adopters have done so not because of personal advantage, but from a desire
to use technology to increase access to healthcare to underserved populations.
While there are legitimate physician concerns about privacy, legality, and
reimbursement, the larger underlying issue seems to be the paradigm shift from a
provider-centered to patient-centered model of healthcare.
Up until the early to mid-twentieth century, it was common practice for
physicians to visit the patients‟ homes to deliver healthcare. In recent years, such home
visits are rare and most physicians have adopted a provider-centered, business model in
which the patients must travel to a physician‟s office or medical center for healthcare.
Telemedicine is one solution that addresses the increasing problem of little or no
access to healthcare for underserved populations living in rural or isolated areas. In
particular, the elderly and poor often have difficulty traveling to healthcare centers for
specialty consultations or for monitoring of chronic conditions.
145
Critical Mass
According to Markus‟ Critical Mass Theory of Interactive Media,158 universal
access, interdependence, and diffusion are necessary to achieve critical mass, the number
of early adopters sufficient to fuel the widespread adoption of an innovation.
Universal access and interdependence may be addressed for telemedicine by the
development of better and more cost-efficient telecommunications infrastructures and
systems. An integrated telecommunications infrastructure is necessary for ubiquitous,
universal desktop access to healthcare. Statewide telecommunications networks could
link healthcare providers with healthcare consumers and allow efficient, long-distance
monitoring of chronic diseases and/or conditions.
The third factor, diffusion, could be enhanced by the integration of telemedicine
technology into professional healthcare education and by in-service training of existing
providers. The adoption of telemedicine and telehealth may be part of a general trend
toward such patient-centered, integrated technologies as electronic multimedia patient
records and “smart cards,” small portable plastic cards encoding patients‟ health
information.
Recommendations for Developing, Growing, and Sustaining a Telehealth Network
Based on this study‟s data collection and analysis, the following organizational
factors are recommended for developing, growing, and sustaining a telehealth network:
158
Markus, 491-511.
146
1) Development of statewide telehealth networks as part of larger statewide and
national telecommunication infrastructure linking schools, libraries, hospitals,
and clinics for multi-dimensional purposes of education, healthcare, and
community development
2) Multiple sources of funding including state funding, federal grant funding, and
internal institutional support. If state funding is not available, other strategies
may be required, such as a network membership fee, a fee for deliverables
such as distance training or CME courses, or a fee for specific telehealth services.
3) Development of integrative, multimedia electronic patient records, secure but
accessible by healthcare providers and by patients
4) A telehealth advisory oversight group composed of key players in state
government, higher education, the telecommunications industry and healthcare
education and administration. Objectives of the group should include
identification of healthcare needs and the development of funding and
implementation strategies to meet those needs via the telehealth network
5) Integration of telemedicine training into physician education and residency
programs, and in-service telemedicine training of existing healthcare providers
6) Adequate staffing of telehealth networks, including a director and/or medical
director (physician), tele-nurse(s), engineer(s) and/or technician(s), and
scheduler(s) and/or administrative assistant(s). Other staff may include project
coordinator(s), research evaluator(s), and education coordinator(s) and/or
trainer(s).
147
7) Marketing of telemedicine and telehealth services to the public and to referring
and specialty healthcare providers.
Recommendations for Further Study
Recommendations for future study include: refining and expanding telemedicine
taxonomy and typology; further developing and refining telemedicine theory; refining
and expanding the survey instrument for broader survey or case study research; and
further research into more specific areas such as budgets and salary ranges.
148
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Implications of E-mail for the Patient-Physician Relationship.” Journal of the
American Medical Association 280 (October 21, 1998): 1353-1359.
Swan, Jacky A. and Sue Newell. “The Role of Professional Associations in Technology
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Sykes, Dianne and William Alex McIntosh. “Telemedicine, Hospital Viability, and
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44 (Jan/Feb 1999): 59-71.
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http://www.harrisinteractive.com/news/newsletters/healthnews/HI_HealthCareNe
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159
APPENDIX 1.
The University of Tennessee
Office of Research
Research Compliance Services
INFORMED CONSENT FORM
“Organizational Structure of Telehealth Care: An Examination of Four Types of
Telemedicine Systems”
You are invited to participate in a research study. The purposes of this study are:
To examine the infrastructure of selected telemedicine organizations and, from
this, develop a model that can enhance network sustainability and growth
To develop an internet survey instrument to determine organizing infrastructure
on a nationwide basis.
The research is being conducted in partial fulfillment for a doctoral dissertation
INFORMATION
The case study method will be used to determine the organizational structure and
location of the telemedicine network within the larger “parent” organization. The
original purpose of the networks will be examined, as well as the history of their
development and factors that contributed to and detracted from network
development. Such factors could be, but are not limited to, funding sources; health
care provider and patient acceptance; technical factors; location within the parent
organization; availability or non-availability of reimbursement; and other factors
that could be discovered through in-depth interviews with key informants within
the telemedicine network under study.
Data sources include:
o Transcripts of interviews
o Documents sent by case study participants
o Case study participants‟ web sites and marketing materials
o Research publications.
160
Key informants from eight different telemedicine networks will be asked to
participate in the study.
Participants will be furnished the interview questions (in advance, online) that
will guide the interview. The „virtual‟ interview will use interactive audio-video
technology in the University of Tennessee Medical Center Telemedicine
Department.
The interview is anticipated to last approximately an hour. If more information is
needed, follow-up phone-calls and/or e-mails may be used.
The data collection time frame is May to July 2001.
The interviews will be audio-taped and transcribed. The audio-tapes, informed
consent forms, and any other materials containing key informants identities will
be kept securely and will be destroyed after analysis. Access to the identifying
materials will be restricted to the Principal Investigator, Teresa Welsh, and her
advisor, Dr. Susan Dimmick.
RISKS
There are no foreseeable risks to the participants.
BENEFITS
The only benefits for participation in this study will be in furthering research and in
increasing the body of knowledge in the field of telemedicine.
CONFIDENTIALITY
The information in the study records will be kept confidential. Data will be stored
securely and will be made available only to persons conducting the study unless you
specifically give permission in writing to do otherwise. No reference will be made in oral
or written reports that could link you to the study.
CONTACT
If you have questions at any time about the study or the procedures, (or you experience
adverse effects as a result of participating in this study,) you may contact the researcher,
Teresa Welsh, at the University of Tennessee College of Communications, School of
Information Sciences, at 865.974.3597 or at 865.573.5030. If you have questions about
161
your rights as a participant, contact the Research Compliance Services section of the
Office of Research at 865.974.3466.
PARTICIPATION
Your participation in this study is voluntary; you may decline to participate without
penalty. If you decide to participate, you may withdraw from the study at anytime
without penalty and without loss of benefits to which you are otherwise entitled. If
you withdraw from the study before data collection is completed, your data will be
returned to you or destroyed.
CONSENT
I have read the above information and agree to participate in this study. I have
received a copy of this form.
Participant's name (print) ____________________________________
Participant's signature _______________________________________
Date ______________
162
APPENDIX 2.
TELEMEDICINE/TELEHEALTH
KEY INFORMANT INTERVIEW QUESTIONS
BACKGROUND QUESTIONS
1. What is the official name of your telemedicine/telehealth system?
2. Is that the original name or has the name changed over time?
3. When and how did telemedicine begin in your organization?
4. Was any sort of needs assessment done in the beginning stages?
5. Is telemedicine a separate department or is it integrated into other departments?
6. How many full-time employees work in your telemedicine system?
7. How many part-time employees?
8. Using Grigsby‟s classification scheme,159 which general applications and
processes of telemedicine do your organization provide?
a. Initial urgent evaluation and triage
159
Jim Grigsby, Robert E. Schlenker, Margaret M. Kaehny, Peter W. Shaughnessy, and Elliot J. Sandberg,
“Analytic Framework for Evaluation of Telemedicine,” Telemedicine Journal 1 (1995), 36-37.
163
b. Medical and surgical follow-ups
c. Primary care consultations
d. Specialty consultations and second opinions
e. Transmission of digital diagnostic images
f. Diagnostic work-ups for specific conditions
g. Monitoring of chronic diseases and conditions
h. Transmission of medical data
i. Public health and education
j. Other
9. Using Reid‟s classification scheme of telemedicine (Level of Service, Setting,
Healthcare Discipline, Technology Used, Equipment, Data Type, Activity
Conducted),160 what level of service(s) does your organization provide?
a. Tele-Consultation
b. Tele-Care
c. Tele-Monitoring/Mentoring
d. Tele-Health Education
e. Other
10. What are the settings (end-user locations)?
a. Hospital
b. Clinic
c. Home
d. Prison
Jim Reid, “Telemedicine Applications: Today and in the Future,” slide presentation (1998). Available at
www.telemedprimer.com/htb1198/tsld001.htm.
160
164
e. Workplace
f. Other
11. What healthcare disciplines use your telemedicine system?
a. Medical specialty (Family Practice, Dermatology, etc.)
b. Nursing (Acute care, Home health, Hospice)
c. Allied health (PT, OT, Nutritionist, etc.)
d. Other
12. What telemedicine technology system(s) are used by your organization?
a. Interactive video
b. Store & Forward
c. Other
13. What kind(s) of equipment is used in this system?
a. Room systems
b. Rollabouts
c. PCs
d. Mobile
e. Set top boxes
f. Other
14. What kind of activity is conducted with telemedicine in your organization?
a. Clinical
b. Educational (Adult, Medical, Nursing, Allied)
165
c. Administrative (Meetings, Recruitment, Compliance Q&A)
d. Business (Community business, Social orgs, Government orgs)
e. Other
15. How is your telemedicine system funded?
a. Grants
b. In-house
c. Insurance reimbursement
d. Other
16. Does your organization collect data and generate reports on telemedicine activity?
a. What kinds of data are collected?
b. Who compiles the data and writes the report? An independent evaluator?
17. Does your organization offer any training in telemedicine? If so, for whom and
what kind?
18. Does your organization market or publicize telemedicine to healthcare
consumers? … to healthcare professionals? If so, what kind?
EVALUATION QUESTIONS
166
19. What do you consider the greatest barriers to the growth of telemedicine in your
organization?
20. What efforts has your organization made (if any) to overcome those barriers?
21. Which telemedicine applications do you consider the most successful in your
organization?
22. What factors do you think have contributed to the success of these applications?
23. What do you define as success in your TM program?
24. What future applications for telemedicine do you think would be successful in
your organization?
25. If you could change anything about telemedicine in your organization, what
would it be?
167
APPENDIX 3. DIFFUSION OF INNOVATIONS MODEL161
161
Everett Rogers, Diffusion of Innovations, Fourth edition (New York: The Free Press, 1995), 165.
168
APPENDIX 4A. ARIZONA HEALTH SCIENCES CENTER ORGANIZATIONAL CHART
169
APPENDIX 4B. ARIZONA TELEMEDICINE PROGRAM ORGANIZATIONAL CHART
Associate Director
Administration
Administrative Assistant
Office Assistant
Case Manager
Medical Services
Case Manager
Medical Services
Technical Coordinator
Training Activities/Tours
170
APPENDIX 5. EAST CAROLINA UNIVERSITY TELEMEDICINE ORGANIZATIONAL CHART
171
APPENDIX 6. EASTERN MONTANA TELEMEDICINE NETWORK (EMTN) ORGANIZATIONAL CHART
Deaconess Billings Clinic
Marketing Division
Kristianne Wilson
Vice President
EMTN
Marketing & Planning
HealthLine
Senior Life Partners
Telephone Communications
3.42 Budgeted FTEs
8.62 Budgeted FTEs
3.49 Budgeted FTEs
2.5 Budgeted FTEs
11.31 Budgeted FTEs
EMTN Director
EMTN Technician
Marketing/Business Development Director
HealthLine Coordinator
HealthLine RNs
SLP Coordinator
SLP Specialist
Lifeline Progam Rep.
Planning/Mkt Analyst
Mkt/Research Analyst
Planning/Mkt Associate
Planning/Mkt Liaison
Mrk Comm Specialist
Mrk Communication Director
Graphic Designer
Marketing Associate
Administrative Assistant
Community Representative
PBXSupervisor
PBX Operators
172
APPENDIX 7A. KANSAS UNIVERSITY INFORMATION RESOURCES ORGANIZATIONAL CHART
Information Resources
Associate Vice Chancellor for Information
Resources
Chief Information Officer
Director, Dykes Library
Academic Administration
Technology
Director
Dykes
Library
Instructional
Multimedia
Budget/
Financial
Digital
Audio and
Video
Billing
Interlibrary
Services
Purchasing
Reference
Contracts
Technical
Services
Faculty
Support
Circulation
Administrative
Internet
Systems
Development
Director
Asst. Director
Analysis &
Programming
Production
Services
Document
Management
Internet
Development
Services
Server
Management
Assistant to
the CIO
Telecom & Telemedicine
Data
Security
Director
Security
Networking
Integration
Director
Director
Administrator
Networking
Customer
Services
Clinical
Issues &
Research
Systems
Integration
Data
Scheduling & Warehouse
Installation &
Services
Development
Maintenance
Paging
Admin Support
Student
Computing Personnel/Payroll
Systems
Telephone
Services
Help Desk
173
APPENDIX 7B. KANSAS UNIVERSITY TELEMEDICINE ORGANIZATIONAL CHART
TELEMEDICINE
Director
Senior Consultant (MD)
Senior Coordinator (MBA)
Researcher
Media
Production
Technician
Media
Production
Technician
Secretary
Telehospice
Researcher
TelekidCare
Researcher
(MA)
Scheduling
Coordinator
Researcher
TelekidCare
Coordinator
Telehospice
Coordinator
(RN)
Researcher
174
APPENDIX 8. MISSOURI TELEHEALTH NETWORK ORGANIZATIONAL CHART
EXTERNAL AFFAIRS
TELEHEALTH
FUNCTIONAL ORGANIZATION
B
EXECUTIVE
DIRECTOR
Exec Director of Telehealth activities
ASSISTANT
DIRECTOR
ADMINISTRATIVE
ASSOCIATE i
Fiscal & HR
Direct Telehealth programs
ADMINISTRATIVE
ASSISTANT
Assist with telehealth activities
COORD
PROGRAM
PROJECT
Monitor clinical
utilization
SR NETWORK
SUPPORT
SPECIALIST
CONT ED
COORD
Coordinates telehealth
equipment & connections
Develop training
programs
USER SUPT
ANALYST ENTRY
Technical/Computer Support
USER SUPT
ANALYST
ENTRY
CURRENT 6/00
Technical/Computer Support
175
Teresa Welsh