ED 165 952

AUTHORTITLE

INSTITUTIONZPONS AGENCY

REPORT NOPUB DATECONTRACTNOTE

EDRS PRICEDESCRIPTORS

IDENTIFIERS

ABSTRACT

DOCUMENT RESUME

RC 011 130

Bennett, '.. M.; And OthersTelehealth Handbook- A Guide to TelecommunicationsTechnology f.',r Rural Health Care.Nitre Corp.. McLean, If z:.

National Centel for Health Services Research(DHEW/PHS), Hyattsville, Md-DHEW-PHS-79-3210; NCHSR-79-1May 78HRA-106-74-182164p.

MF-30.83 HC-$8.69 Plus Postage.Administration; Costs; *Delivery Systems; Guides;Health Education; Health Needs; Health Personnel;Information Networks; Information Systems; *MedicalServices; Patients (Persons); *Primary Health Care;*Thiral Areas; Rural Population; *Telecommunication;Telephone Communication Systems; Television*T,?lehealth System

Emphasizing. primary care, this handbook focuses onthe application of specific types of telecommunications technology tothe process of information exchange within a rural health caresystem. Its purpose is to provide guidance to health care plannerswho want to consider the potential of telecommunications technologyEor iLproving quality, accessibility, and efficiency of care- Takinga functional, applications-oriented approach, it integrates theissues and recommends a decision-making process. The range oftechnologies discussed includes not only the expensive and exotic butalso the rather inexpensive, everyday technologies that should beavailable in many parts of the country- Content includes backgrouLdtaterial cn health care and information exchange; the concept of anetwork and the diszinction between telecommunications links and?nd-instruments; functional applications of telehealth systems(patient care management, administration, edi,cation): technical:omponents of telehealth--transmission (ni:rrowband, telephone, radio,)roadband, networks), end-instruments (audio, telemetry, data/rec-Ird,rideo, slow-scan television, patient-viewing video devices) ; processor assessing feasibility of telehealth in a specific setting; eying:or telehealth. More than !..) current and planned telehealth projectsLnd references for additional information are briefly descri:oed,[RS)

:**********************************************************************Reproductions supplied by EDRS are the best that can be made

from the original document-.**********************************************************************

MI4E4014HANDBOOKa guide totelecommunicationstechnology forrural health care

U S DEPARTMENT OF WEALTH.EDUCATION & WELFARENATIONAL INSTITUTE OF

EDUCATION

THIS DOCUMENT HAS BEEN REPRO-DUCED EXACTLY AS RECEIVED FROMTHE PERSON OR ORGANIZATION ORIGIN-ATING I. POINTS OF VIEW OR OPINIONSSTATED DO NOT NECESSARILY REPRE-SENT OFFICIAL NATIONAL INSTITUTE OFEDUCATION POSITION Or. rOory

US DEPARTMENT OF HEALTH, EDUCATION. AND WELFARE Public Health Service National Center for Health Services Research

17_

-

tw

ABSTRACT

ToIc,health is a term applied to the use of telecom-munications technology to facilitate the delivery ofhealth care and services among remotely located, geo-graphically dispersed, or physically confined persons.A telehealth system appears ro b, valuableresource for improving access r.o quality health carein rural areas. Telehoalth systems can enhance theinformation exchange that is vital to providing qual-ity health care and help reduce the professionalisolation of rural providers. With an emphasis onprimary care, this Handbook focuses on the role oftelecommunications technology in the exchange ofpatient, educational, and administrative informationwithin a dispersed health care system. Although theemphasis is on planning for rural communities, wherethere is a severe shortage of health services, theresources, concepts, and issues are applicable tourban areas also. The intent is to provide prell7inLryguidance to health care planners who are consiatelehealth among the many alternatives available f,/-improving the quality, accessibility, and efficien2yof care.

3

TELEINVALTH

a guide totelecommunicationstechnology forrural health care

prepared for theNational Centerfor Health Services Researchby the METREK Divisionof the MITRE Corporationunder contract HRA-106-74-182

A.M. BennettW.H. RappaportF,L. Skinner

DHEW Publication No (PHS) 79 -3210May 1978

INITED STATES DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE U Office of me Assistant Secr.qary for Health O, Na;onat Center for Health Services Researc

ACK NOW LEDGEMENTS

The METREK Division of The MITRE Corporationacknowledges the efforts and cooperation of the zanypersons who provided information and a ice in thedevelopment of this Handbook. We wish to expressappreciation to many of the telehealth projectdirectors listed in the Handbook Appendix; equipmentmanufacturers; health care providers; and to METREKstaff members Carol Anderson, Lynne Phillips, andSeymour Gresser, who provided medical and technicalinformation and editorial advice.

Dr. Maxine Rockoff, of the National Center forHealth Services Research, guided the development ofthe Handbook from i concept to completion.

Additional copies of rCHSR publications are available onrequest from the NCHSR Publications and Information Branch,3700 East-West Highway, room 7-44, Hyattsville, MD 20782(tel.: 301/436-8970).

FOREWORD

This Handbook for potential users of telecommunications technologyin health services delivery is a marked departure from traditionalNational Center for Health Services Research publications. The Hana-book is not a summary of research results in the usual sense, butrather a gathering of the collective know-how of those who have beenexperimenting with and thinking about health care applications ofthis technology.

NCHSR began a vigorous telehealth research program in 1971 withseven exploratory two-way visu:1 telecommunications projects. Thesewere intended3 to: (1) gain "clinical impressions" of the utilityof this technology in a wide variety of health care settings andapplications; (2) develop methods for assessing the utility of thetechnology; and (3) develop a framework for further research on thelogistics of health care delivery.

Major analytical difficulties are inherent in telehealth researchbecause the technology may significantly alter the organizational struc-ture of tne health care system in which it is placed. Moreover, th.zreare many variations in the kinds of technology available and in thefunctional applications to which these technologies may be addressed.These difficulties surfaced in NCHSR's exploratory projects and wedecided to focus additional research on overcoming them.

The kinds of questions we tried to answer included: Could onedevelop analytical tools that would help narrow the range of researchand demonstration projects and field trials that should be funded?Could one predict, prospectively, what the impact of technology wouldbe? Could one use such predictions both to select promising candidatetechnology/site combinations for demonstration and to evaluate thedemonstrations?

is

4

This Handbook is part of our progress in developing "yes" answersto these questions. The Mitre Corporation has been under contract toNCHSR since 1972, studying the telecommunications technology that wouldbe appropriate to support the delivery c: health care services in ruralareas. A series of reports resulted 4,8,10,26,30,31,32,33,34,35,36 on

both the analytical work and on the prospective assessment of variousmanpower/technology combinations that would be likely to have favorablebenefit-to-cost ratios. The next logical step would be to initiateprojects that appear favorable, prospectively, based on analysis ofsite-coecific needs and technology options available. This Handbookhas been developed to provide initial information and guidance topotential users of telecommunications technology who might be in-terested in undertaking a telehealth project.

One of the most important conclusions of the Mitre researchwas that telephone-based technologies should be exploited muchm-,re vigorously than had been the case in past government-fundedresearch. Hence, this Handbook discusses a range of ':echnologiesincluding nct only expensive, exotic, technologies but also ratherinexpensive, everyday, technologies that should be readily availablein many parts of the country.

Our purpose is well served if this Handbook alerts the healthcommunity to the exciting possibilities that telehealth offers to-crease access to affordable, high quality health care services,

aL the same time encouraging the adoption of only those technologicalapproaches that are approprir.ce and sound.

Gerald Rosenthal, Ph.D.DirectorNational Center for Health Services Research

May 1978

iv

PREFACE

With an emphasis on primary care, this Handbook focuses onthe application of specific types of telecommunicationstechnology to the process of information exchange within arural health care system. Although rural communities pro-vide the basis for discussion, the resources, concepts, andissues are generally applicable to urban areas as well.The intent of the Handbook is to provide guidance to healthcare planners who want to consider the potential of tele-communications technology for improving the quality, accessi-bility, and efficiency of care. A functional, applications-oriented approach has been taken and an attempt has beenmade to integrate the issues and recommend a Jecision makingprocess to those who are investigating telehealth's feasibility.

The authors have not attempted :o provide an exhaustivetechnical coverage of telecommunications or an encyclopedictreatment of telehealth. This publication should be usedas a practical guide to aid the reader in deciding whethez,to implement some form of telecommunications tc supportpatient care, educational, or administrative activities andhow to approach the design process. It provides information-.o assist the reader in answering questions such as:

Would a telehealth system improve the delivery ofhealth services in my community?

Is it economically, socially, and politicallyfeasible to establish such a system in my community:

How does one begin to design such a system? Whatare the d(sign alternatives and tradeoffs, andwhat equipment should be considered?

Section 2 of the Handbook introduces some ideas that arebasic to telehealth--the concept of a network and the dis-tinction between telecommunications links and end-instru-ments. Section 3 focuses on the functional applications

of telehealth systems -- patient care management, education.and a(!ministration. Sections 4 and 5 describe the technicalcomponents of telehealth,.and sectie: f discusses a processfor assessing the feasibility of telE+ .alth in a specificsetting.

If one has. had experience with telehealth systems, the Htl.od-book may he used to explore particular issues. If telehealthis new to the reader, he may wish to skip some of the dctailedtechnical material in sections 4 and 5. The Handbook shouldbe regardeC as a source of information and a guide to theronsideration of telehealth for specific purposes, ratherthan as a "cookbook" which dictates explicit solutions. Theapplication of telehealth systems is an expanding field; theHandbook is aimed at facilitating its appropriate and Effec-tive expansion.

vi

4

CONTENTS

Foreword

Preface

1 Introduction

Page

Background 2Health Care and Information Exchange

2 The Telehealth System Concept

3

5

Defining the Telehealth SystemTelehealth System Structure 6End-Instruments 7

Telecommunications Links 8Basic Telehealth System

3 Functional Applications of Telehealth Systems 11

Patient Care/Management ApplicationsDiagnostic Information ExchangesConsultative Information Exchanges 12Instructional Information Exchanges

Administrative Applications 13Edrcational Applications 14

Physician EducationNon-Physician Education 15Patient Education 16

4 Telecommunications Systems - The Technology ofTransmission 17

Narrowband Telecommunications SystemsThe Telephone System 18Structure of the Telephone SystemTelephone System Economics 19Specialized Telephone Devices and Services 20Additional Local Capability 21Cost Improvement Services 23

vii

Page

Quality Improvement Services 23Radio Extension of Telephone ServiceSummary of Telephone Systems 24

Radio Systems 25Broadband Communications Systems 27

Transmission MeansMicrowave Radio 28Broadband Cable

Networks 29RadioWireline 30

5 Telehealth End-Instrument Systems 31

End-Instrument ConceptsAudio Instruments 33Telemetry Instruments 38Data/Record Instruments 39

Teletype (Alphanumeric) Data Transmission 44TrJge-Type Data -ransmission

Video Instruments 45The Video Camera 50NTSC Standard-Quality Television 51

Slow-Scan Television (SSTV) 53PrinciplesCapabilities 55Applications 56

Patient Viewing Video Devices 60Examples of End-Instrument Configurations 61

6 Telehealth System Implementation 67

Defining and Evaluating the Telehealth Alternatives 68Stage I: Determination of System RequirementsFunctional RequirementsStructural RequirementsPerformance RequirementsData Collection for Determining Requirements 70

Stage II: Identification of System ConstraintsStage III: Definition of Telehealth SystemAlternatives 72

Stage IV: Comparison of System Alternatives 73Functional Performance CapabilitySystem Costs 76Other Factors 77

Stage V: Selection of System Approach 78Initial Questions 79Example of the Selection Process 80

viii

4

7 Paying For Telehealth

Page

35

Who Incurs Telehealth Costs?Who Receives Telehealth System Benefits? 86Patient BenefitsProvider Benefits 87

Health System BenefitsWhat Are Appropriate Telehealth Payment/Reimburse-ment Mechanisms? 87

Appendix - Telehealth Project Summaries 91

References 747

Figures

1 A Hierarchical Model of a Health Care System 4

2 A Network RepresentLtion of the Telehealth System 63 Basic Telehealth System Elements 7

4 Point-to-Point and Switched Networks 185 Linear Three-Hrp Simplex Microwave Network 296 Slow-Scan TeleOsion Functional Diagram 547 Video and Audio System 618 Data Oriented End-Instruments 629 Two-Way Audio System 6310 Acoustic Coupled Telemetry 6311 Facsimile and Slow-Scan End-Instruments 6512 Some Medical-Specific End-Instrument Systems 6613 Determining the Desirability of a Telehealth Approach 69

Tables

1 Narrowband Communication 172 Summary of End-Instruments 323 Audio(Speech)End-Instruments 344 Telemetry End-Instruments 405 Data/Record End-Instruments 426 Video End-Instruments 467 Summary of Some Slow-Scan and TV Devices 578 Detailed Site Data Collection 71

ix

4

I INTRODUCTION

The problems associated with providing adequate health carein rural 2teas include a shortage of providers, sparselydistributed populations that frequently are poorer andolder than in non-rural areas, geographic barriers, poorroads, climatic extremes, sub-standard housing, and poornutrition. During the past decade, many approached havebeen implemented to ease the problems of medically under-served areas. New educational programs have been designedto increase the numb.r of primary care physicians in ruralareas; organizational innovations have been encouraged thatemphasize the regionalization and coordination of servicesand facilities; and, increased reliance on satellite healthclinics and non-physician providers has been advocated.

In conjunction with these innovative progra:amatic andorganizational approaches is a growing interest in-theuse of telecommunications technology to support healthcare. Improved communication systems can enhance theeffectiveness of both existing and new health care deliveryapproaches and extend the accessibility of health careservices to rural populations. These capabilities haveresulted in the emergence of "telehealth"* - the applicationof telecommunications-based technology in the delivery ofhealth care and related services. Telehealth systems showconsiderable promise for enhancing linkages among elementsof a health care system by making remote services availablelocally and improving the.flow of educational and admin-istrative information. These linkages,.in turn, should:

*The term "telehealth", rather than "telerepdicine", is usedin this Handbook because it implies a broader range ofhealth-related activities, including patient and providereducation and administration, as well as patient care.

1

reduce patient travel am'. inconvenience,

improve the r.ontinuity of care,

enhance the quality and timeliness of care,

improve the financial status of rural healthsystems, and

reduce providers' feelings of isolation.

Background

Telehealth began in the mid 1960's with systems using off-the-shelf electronic equipment to facilitate physician-to-physician consultation, emergency medical services, andadministrative activities. Concurrently, the NationalAeronautic and Space Administration's medical telemetrywork in the manned spaceflight program led to the develop-ment and application of new technologies to health caredelivery problems.

An increasing number and variety of telehealth projectsrepresenting a broad range of technologies are beingapplied in rural, urban, and academic settings. Thehistorical development of telehealth, as well as discussionof alternative applications, implementation and evaluationissues can be found in Park's An In.roduction To Tele-medicine,' and Bashsur, Telemedicine: Explorations inthe Use of Telecommunications in Health Care.2 Technicalimplications and considerations are discussed in an IEEETransactions on Communications article by Dr. Maxine L.Aockoff of the Nct_onal Center for Health Services Research,"An Overview of Some Technological Health Care SystemImplications of Seven Exploratory Broadband CommunicationExperiments."3

Since the inception of telehealth, experience has shownthat it is technically feasible to provide remote commu-nications support to rural health professionals. 'Tele-phone communication augmented by instrumentation willpermit the encoding and decoding of clinical, administrative,and educational information in a variety of forms, assuccessfully demonstrated in a number of_programs.2 Tele-phone technology, as opposed to the considerably moreexpensive and complex alternative of television trans-mission, 'is currently the most cost-effective form of tele-health. However, many operational questions and untiedalternatives remain to be explored. These alternativesconcern the utilization of various levels of technology

2

14

by different types of providers, cost and revenue implica-tions of different celehealth approaches, training require-ments for acquiring skill in the use of telehealth equip-ment, and the range of services that can be effectivelyaugmented through the use of telecommunications.

Health Care and Information Exchange

Health care is a communications-intensive process. Informationis constantly being exchanged anong providers and betweenpatients and providers relative to problem diagnoses andtreatment plans. Administrative activities depend heavilyon the exchange of information in a rapid, efficient mannerand education is inherently an information exchange process,whether it be patient- or provider-oriented.

A telehealth system does not create new or more preciseinformation. Rather, it provides the capability to ex-change information more efficiently and more broadly toimprove decision-making and the delivery of health services.

Telehealth systems have been used to facilitate clinicalactivities by the transmission of heart and breathing sounds,patient images, bacteria and tissue slides, x-rays, andelectrocardiograms. Computerized patient records have beenimplemented in several telehealth systems* and a few compre-hensive health information systems are being developed.Elaborate educational networks based on telecommunicationstechnology have been established to facilitate continuingmedical education on a regional basis.

The role of telehealth is simply illustrated in Figure 1 inthe context of the hierarchical organization that definesmost health care systems. Typically, a telehealth systemlinks multiple levels of health care. For example, asecondary -_are facility may be connected by means of a commu-nication link to one or more physician-staffed primary caresites and to other_hospitals; primary care clinics', in turncan be linked to satellite primary care sites staffed bynon-physician providers. Telecommunications linkagesbetween these sites can be used to provide consultation,education, and other support services to patients and pro-viders.

*See Appendix. This Appendix contains brief descriptionsof more than 50 current and planned telehealth projects aswell as contact persons for most projects and referencesthat may be consulted for additional information.

LLLLL L L LLLLLLLLLLLLLLLLLLLLL

MEDICAL CENTER

LLLL LL 0HOSPITAL SPECIALTY

0E3MEDICAL

I\\ SERVICES\ I\\ I

/\

PUBLIC HEALTH AGENCY0 El

PRIMARY-CAREMENTAL HEALTH AGENCYEXTENDED CARE FACILITY / I CLINIC

PHARMACYLABORATORY

4

FE711

SATELLITECLINIC

SATELLITECLINIC

PRIMARY CARECLINIC

TERTIARY CARE

SPECIALIZEDMEDICAL, SURGI-CAL, AVD DENTALCARE.

SECONDARY CARE

GENERAL MEDICAL,SURGICAL, ANDDENTAL CARE

PRIMARY CARE

PREVENTION, CASEFINDING, DIAG-NOSIS, AND TREAT.MENT OF UNCOMPLI.CATED MEDICAL ANDDENTAL PROBLEMS.

Figure 1A Hierarchical Model of a Health Care System

16

2 THE TELEHEALTH SYSTEM CONCEPT

Telehealth systems involve the use of telecommunications-based technology to facilitate the delivery of healthcare and other related services among geographicallydispersed persons. This section identifies and describesthe components that could be used to develop a telehealthsystem. Familiarity with these components, capabilities,and specific characteristics is ;he first step in con-sidering whether a telehealth approach is appropriate fora particular health care delivery situation.

HoweVer, descriptions of telehealth system componentswould be relatively meaningless without some considerationof the health care functions supported by these components.Therefore, in the next few sections both the nature andcapabilities of system components and their potentialfunctional roles in a telehealth system are discussed.

Defin'.ng the Telehealth System

A telehealth system is essentially a support s-stem. "Tele-health" refers to a telecommunication-based system thatsupports those functions which have long been establishedas part of the process of providing health care services.The nature of the support provided is simple in concept,but vital to the health care process. Telehealth systemssupport the health care process .by providing the means formore-effective and more efficient information exchange.Therefore, one can consider any collection of health carelocations that exchange information as a telehealthsystem. As such, informal telehealth systems are extremelycommon in many present methods of health care delivery.For example, Informal telephone consultations occurfrequently between physicians. Administrative detailsrelated to arranging medical conference agenda, patientbills or records, and inventory matters oft-en are handledthrough telephone conversations. Surgical operations areshown on closed circuit television systems fcr medicaleducation.

5

Telehealth System Structure

Figure 2 presents a telehealth system as a network withvarious locL.tions represented by nodes (points) connectedby links (lit..-:s). This network of points and lines isthe most general form in which the structure of any tele-health system can be represented. It identifies theparticipants (locations) and, through the lines connectingthem (links), indicates which ;anticipants are engaged ininformation exchange. From t1 is network point of view, thesimplest form of a telehealth system consists of only twopoints interconnected by a line, i.e., two locationsexchanging information over some form of telecommunicationslinkage_

6

TERTIARY\HOSPITA L

EXTENDEDCAR EFACILITY

PRIMARYCARECLINIC

Figure 2A Network Representation of the Telehealth System

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Within this simple configuration, end-instruments and acommunications link form the two basic technical components,or system elements, within a telehealth -system. Figure 3Illustrates these two basic elements.

END-INSTRUMENT

INPUT TRANSDUCER

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TELE-COMMUNICATIONSLINK

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OUTPUT TRANSDUCER

Figure 3Basic Telehealth System Elements

End-Instruments. End-instruments are the transducers thatinterface between human participants and the link of thecommunication system. The input transducer converts a:hysical phenomenon, such as speech, into an electricalsignal; the telecommunications link transmits the signal somedistance; and the output transducer converts the receivedelectrical signal into a representation of the input phenomenon.

7

specifically related to the function being performed. Rather,the telecommunications link must be suitable to the type ofelectrical signal which is generated by the end-instrumentand which must be transmitted over the telecommunir.ati,nsline. In that sense, the telecommunications link is"transparent" to the type .-)f information being sent.However, there are significant cost differences betweennarrowb--d and broadband telecommunications links and thesemay cc rain the type of link that can be used. The end-inst3 should be selected to do the most effective job

-straints.

9

3 FUNCTIONAL APPLICATIONS OF TELEHEALTH SYSTEMS

A telehealth system is specifically aimed at facilitatingtimely information exchanges among patients and profassionals,especially where the users are separated by great distances.These exchanges of information have been categorized intothree functional applications of telehealth systems:

s Patient care/managementAdministrationEducation

Patient Care/Management Applications

Patient care/management covers the broad scope of informa-tion exchanges related to the care of individual patients.Although the scope of these information exchanges may varyover the entire range (3.2 patient-related services, threetypes of information exchanges characterize patient careactivity in a telehealth sys.tem. These are designated as(1) diagnosis, (2) consultation, and (3) instruction.

Diagnostic Information Exchanges. Diagnostic exchangesare those in which information flows mainly from the patientlevel to the provider level. Diagnostic exchanges mayinvolve the transmission of patient history information,vital signs, test results, telemetry, or visual images ofthe patient. The important factor in this type of exchangeis the orientation of the telehealth system to provide maximuminformation flow from the location of The patient to thelocation'of the consulting provider. This type of flow isgenerally referred to as "upline", since it is typicallyassociated with information flowing from primary or secondarycare levels to higher care levels.

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available, the educational cpportun-,,ties are often foregonebecause of the significant travel burden.

Patient Education. Patient education may be classified interms of its intent, which is usually prevention ordisease management. Preventive patient education activitiesinclude dental health, personal hygiene, prenatal care,ane breast self-examination. Such educational programshave been conducted over commercial television, publictelevision, radio, and similar forms of broadcastcommunications. This form of telehealth system utilizationis a substitute for people meeting to receive directinstruction.

Disease management education takes a form similar to thatof prevention. Topics might include diabetes, obesity,hypertension, and other chronic care problems. Educationfor prevention differs from education for disease managementin that disease management requires more personalizedpatient instruction and, therefore, more interactive formsof telecommunications.

The benefits of telehealth systems in the education areaare of two general types. First, telehealth systems maysubstitute communication for more costly travel. Second,telehealth systems may provide the means for educationalactiviles which would otherwise not be available-

.

16

4 TELECOMMUNICATIONS SYSTEMS-THE TECHNOLOGY OF TRANSMISSION

The two major types of telecommunicatiorts linkages - nar:ow-band and broadband - have been described briefly. Thissection discusses in more detail the major forms of theselinkages, their operating capabilities, their limitations,and their special relationship to the functional applicationsof telehealth systems. Those readers who wish to-skip moretechnical aspects of the discussion of telehealth systemsmay prefer to omit this section, and section 5 which describesand classifies typical end-instruments used in a telehealthsystem.

Narrowband :elecommunica-ion Systems

Narrowband systems provide the capability of transmitting upto 3,000 cycles of Information per second. This bandwidth issufficient for the types of communication listed in Table 1.

Table 1Narrowband Communication

Audio or Speech CommunicationTelephone, radiotelepnone

TelemetryEKG, electronic stetho:-,Fcope

Data/Record CommunicationLow-speed data communications at 10 to 3')

words per minute rate

Still Image TransmissionFacsimileSlow-scan television

17

Two basic forms of communication used for implementingnarrowband transmission are wireline systems ard radiosystems. The most important wireline system for purposesof telehealth is the telephone system. The most commonform of radio system used in health care delivery is mobileradio which is used extensively in support of emergencymedical services.

The Telephone System

The telephone system has become such an integral part of oursociety that it usually is not thought of as a formalcommunication systemit simply is there. The telephone'subiquity, coupled with its high degree of performance,reliability and operational familiarity, makes it an extremelyvaluable resource for.telehealth applications. The telephonevalue is further enhanced by the fact that any telephoneinstrument can be interconnected with any other instrumentin the country through the switching network. The distinctionbetween point-to-point and switched networks is illustratedin Figure 4.

C

B 60. E

A011C- -0 F

Figure 4a Figure 4bPoint-to-Point Network Switched Network

Figure 4Point-to-Point and Switched Networks

Structure of the Telephone System. Figure 4a shows a simplecommunication network in which a messagt from A to E mustgo through B, C, and D. Similarly, a message from B to Dmust also go through C preventing the-'r simultaneous use ofthe network. A switched network, which is represented byour present telephone system, Is shown in simplified form inFigure 4b. This type of system allows simultaneous18

utilization by a number of parties. A can go through theswitches to E while B and C, as well as D and F, are connectedsimultaneously. Many paths are available between switches.

Because the telephone system is so widespread geographically,numerous device_s have been developed to permit end-instrumentinterfaces. The most familiar interface device is the acousticcoupler. This permits data communication dev14.tes such asteletypes and computer terminals to be connected to the tele-phone system by placing the telephone receiver in thecradle of the coupler. This, and similar interfacing devices,permits the telephone system.to be used with a large numberof end-instruments without direct wiring of the devices tothe telephone line. These interfaces enable the telephonenetwork to be used for the transfer of voice data, facsimile,slow-scan video, or telemetry information. It should benoted, however, that the signals of other than voice devicesmust take turns transmitting in a two-way, two-wire system.This is known as "half-duplex" transmission.

Telephone System Economics. There are significant economicbenefits in using the telephone system. Since the systemalready exists, no significant capital investment is requiredfor telecommunications links. Further, the system is pro-vided as a service and thus requires no user maintenance ..)roverhead activity. Telephone system service generally ispaid for on a per-call basis and is added to a basic monthlyconnection charge. Often single-call charges are made forlocal calls while "time-and-distance" charges are generallymade for long-distance calls.

Although the quality of the telephone system linkage is good,upon occasion the switched system may generate routings ofindividual calls which result in poor transmission. Wherethe circuit quality is of crucial importance to the user,full-time leasing of a "dedicated" line may be obtained.This type of service provides a fixed routing which, for afixed monthly cost of about five dollars per mile, is always:available to the user.

In a rural telehealth sys '-em, telephone users typically areat locations regulated by long-distance rate tariffs. Tominimize communications costs, telephone lines must be usedas efficiently and as quickly as possible- Long-distancetelephone use is not limited to a time-of-use basis. WATS(Wide Area Telephone Service) which is characterizedby package billing for long distance calls made within aspecific time period, is becoming quite extensive. Thesignificant monthly charge for WATS service is economicallyattractive, however, only if a large volume of calls mustbe made.

19

3

No general guidelines can be given about the typicalcost of a telephone-based telehealth system. The cost permonth will depend upon a large number of complex factors,including the number of sites that must be interconnected;distances between sites; the volume of calls between thevarious sites; the length of individual calls; when callsare made; and which sites in the network are locatedwithin the same local, state, or WATS calling regions.

Selection of service alternatives and estimates ofoperating costs are co.nplicated by the fact that althoughinterstate long-distance rates are set on a national basis,intrastate long-distance rates are governed by stateutility commissions and differ from state to state. Thus,tradeoff analyses for selecting the best network configu-ration to use in a telephone-based telehealth system forone rural location will not necessarily apply in anotherlocation.

An example of a hypothetical system illustrates some ofthe factors. F!_xed telephone costs for two telephonenumbers on separate lines are $60.00 per month. Variablecosts for intrastate long-distance charges during the dayand occasionally at night (30 calls per month at $1.00 percall) are $30.00 per month. Thus, the basic telecommuni-cations costs are $90.00 per month for telephone-onlytelehealth support. Telephone systems are not likely tobe more costly than alternative approaches to telehealth.On the contrary, despite the long-distance charges, atelephone-based system is likely to be the least expensiveapproach for telehealth systems.

Specialized Telephone Devices and Services. Another majorfactor in the attractiveness of the telephone system is theavailability of many specialized devices and services whichincrease its flexibility. These devices and services maybe grouped as follows:

1. Additional local capabilityhands-free telephone .operation (Spea':erphone)call-waitingcall-forwardingconference bridgingautomatic answering

2. Cost improvement of serviceWATS service

3. Quality improvement of servicededicated and conditioned lines

20

4. Radio extension of telephone servicepagerpager plus voicemobile radio telephone

Additional Local Capability. This category includes a numberof capabilities that can be obtained from a local telephonecompany or by the addition of hardware at the subscriber'sterminal. One is a hands-free capability that allows one ormore persons to have telephone conversations without theneed to hold the telephone. The equipment consists of hard-ware which allows the user to push a switch, hang up -hehandset, and continue tba conversation, generally fromanywhere ina room. This type of device, although simpleand familiar, can be an extremely useful adjunct for medicalconsultation during a patient encounter. The same hardwarealso can be used effectively for administrative or education-al purposes with group participation at a single telephonelocation and all parties equally involved in the conversation.

Call-waiting is a service that provides a person using thetelephone with a signal indicating that an incoming call isringing. The subscriber may put his present call on "hold"and answer the incoming call. The second call may also beput on "hold". Such a service is useful in emergencysituations.

Several additional advantages accrue from such a service.First, 1= may not be necessary to have an additional tele-phone number with its associated fixed monthly charge;second, potential patients may not call again if they receiverepeated busy signals. The call-waiting service is availableonly from telephone companies and only in selected locations.

Call-forwarding enables the automatic relaying of an incomingtelephone call to a different number than the one originallydialed. The simplest form of such a capability is thesele that can be obtained from some telephone companiesfor 4-proximately $1.50 per month. It permits the user todesigna:e P single number to which incoming calls will betransferred automatically whenever a switch is thrown onthe telephone instrument. Customer-purchased call-forwardinghardware may be attached to a standard telephone instrument,permitting the user to enter the additional number to whichincoming calls may be forwarded.

The use of call - forwarding equipment is attractive for anumber of rural health situations. For facilities that arestaffed only part-time, call-forwarding services couldautomatically redirect inquiries to a location where a

21

provider is available on a 24-hour basis. The use of call-forwarding to provide back-up service for rural sitesstaffed by non-physician providers was investigated in arecent feasibility study.° This study demonstrated thatuse of call-forwarding in combination with direct-distancedialing would permit a group of five nurse practizioner-staffed clinics to rotate their after-hours back-upservices. These clinics, separated by as much as 200 miles,could have their after-hours calls handled by one of thefive practitioners on a rotating basis. If the callerrequired personal assistance, the back-up nurse practitionerwould notify the local nurse practitioner. Alternatively,after-hours calls could be routed automatically to adistant hospital emergency room which would assess theneed for direct local assistance. This kind of technologywould be very helpful in communities that are too small tosupport more than one nurse practitioner.

Conference bridging permits several locations to be inter-connected for a group conversation. Conference calls areparticularly attractive for consultations involving multiplelocations. For example, a non-physiian provider may bee scussing a case with a distant preceptor who wants toinsult a specialist remote from both of them. Conference

calls are also useful for administrative and educationalapplications. However, the rate structure for conferencecalls, which would generally involve operator-assisted,long-distance calls,* may be excessive for frequent andlengthy educational activities.

Answeri-Lg services, a common telephone system feature , allowsincoming calls to be diverted to an individual who takesmessages for persons not available to answer their owntelephones. However, there has been a great increaserecently in the use of automatic telephone-answering devices.These devices play a taped message to incoming callers andusually permit the caller to leave a recorded message forlater playback. Automatic answering can be used in ruralhealth applications in lieu of' call-forwarding. Forexample, the recorded message played to the caller couldindicate a number for Lbe caller to dial if immediate helpwere needed. If the condition were not considered urgent bythe caller, a message could be recorded asking for an appoint-ment or requesting a call from the provider during regularclinic hours.

*Telephone systems with Electronic Switching Servicecan provide 3-party conference bridging without operatorassistance.

22

Cost Improvement Services. Telephone companies offer manyspecial cost reduction services. The Wide Area TelephoneService (WATS) is the most prominent and the most applicableof these services for telehealth systems. Outbound WATSpermits an unlimited number of calls to be made from a singlenumber within limited geographical regions for a fixedmonthly charge. Some restrictions, such as in the number ofhours of use, may exist. Inbound WATS permits an unlimitednumber of incoming Calls to a single number from outside thelocal calling area without the caller incurring long-distancecharges. This is the familiar toll-free 800 area numberused extensively by business organizations. WATS may beobtained for intrastate as well as interstate services.

Quality Improvement Services. There are occasions when thequality of telephone service is inadequate. This may be dueto switching problems (disconnects, false busy signals, orlarge noise tran-ients that destroy information, poor linequality such as c:,s-talk from other phone conversations, orlow signal level!:.., Tcese problems are particularly prevalentin rural lines* c,-.1tral offices. Although the inherentredundancy of s .7_ten permits conversations in spite ofsuch problems, ,:err-_ptions are very distracting. In imagetransmission, c13,11ty can render the system useless.

An improvement L -2,.lice quality can be obtained by theleasing of ded- lines. Leased lines are between spe-cific pcints, tm,; ale always connected, and they are notswitched. Lines may be selected to provide lowerlevels of interference and conditioned to minimize othertransmission problems. Such conditioned lines are espe-cially useful for the transmission of digital (computer)data and slow-scan images. Costs of leased and conditionedlines vary widely, ranging from $.50 to $8.00 per mile permonth, depending upon locally or federally set tariffs.

Radio Extension of Telephone Service- Two types of radioextension services are used frequently in health-relatedcommunications to link the telephone system to mobile users.These services involve the use of pagers or mobile radio-7-telephones. Most physicians are familiar with paging services.Their simplest form relies on the familiar "beeper" which isactivated upon receipt of a coded radio transmission- Thepager emits a tone to alert the person being paged.toinitiate a return call through the normal telephone system.

*There are more than 1600 independent telephone companies inthe United States, many of which serve rural areas.

23

Paging systems are available which interconnect directlywith the telephone system. In this type of system theperson initiating the page can dial an additional seriesof digits to initiate the automatic paging transmission.These services may be used to alert health care providersor to facilitate administrative activity.

Paging services need not -o-t limited to a simple "beeper".There are systems which pe-mit a ten-second message tobe broadcast to the receiver indicating, for example,what number one should call or to what location one shouldproceed. Only the designated recipient hears the message.This service does not permit the person being paged toreturn any messages via the radio link.

The mobile radiotelephone involves the coupling of radiotransmission to the wireline telephone system, thus estab-lishing a link between a moving vehicle and a fixedtelephone station. In some instances these services arecompleted in a semi-automatic fashion, requiring a telephonecall to a special mobile phone operator for completing theconnection. In most cases the system operates automatically,with the dialing of the mobile number automatically ini-tiating the interconnection to the ra.io link. Suchservices are used frequently in heal'n applications toreach mobile providers or administrators with whom inter-action is necessary or who must be alerted to the need forspecific action.

Summary of Telephone Systems. The foregoing paragraphshave described a number of the services and capabilitiesof the telephone network and have indicated the advantagesof the telephone system; namely its ubiquity, switchingcapabilities, low cost per individual use, lack of capitalinvestment for transmission links, ease of access, andreliability of service. In addition, several specific add-on capabilities have been cited for their potential use-fulness in relation to health care activities. Disadvan-tages in the use of the wireline telephone system includethe limited information rate of speech communications,the possibility of lower telephone service reliability andquality in isolated rural areas, and the costs of long-distance calls which are likely to be more significant inrural areas.

Currently, no specific statement may be made about thequality of rural telephone systems or the ability ofthese systems to support all the services described. Thetelephone companies involved in each potential applicationshould be consulted with respect to their capability forsupporting potential telehealth configurations.

24

Radio Systems

Narrowband radio transmission systems are of two generaltypes -- broadcast and point-to-point. Broadcast communica-tion is typified by commercial AM and FM radio stations.Broadcast stations transmit at established frequencies in agenerally omnidirectional fashion. Inexpensive receivers areavailable that can tune to these frequencies for programmingthat may be scheduled well in advance, and for which pro-gramming information can be made widely available.

Broadcast systems, because of the one-way, one-to-many natureof their transmission, are effective largely for generalpublic interest announcements or specialized educationalprogramming. In many areas radio systems are being used foreducational programming and special educational programs ofinterest to physicians are being sponsored regularly. Insome instances special programs, received only by speciallymodified receivers, are broadcast along with the normal pro-gramming of FM radio stations. This service, known as SCA,is available for a charge and on a limited basis because mostareas have only a few FM broadcast stations.

Point-to-point radio links may be established between fixedpoints or between a fixed point and several moving points.Such radio links provide a half-duplex *, voice-grade circuitand usually are implemented using high-power base stationsoperating at frequencies and bandwidths designated by theFederal Communication Commission (FCC). In most mobileoperations, the high-powered base station is utilized inconjunction with lower powered transceivers** in the mobileunits. mince there is only one channel, many users must taketurns sharing it. Sometimes this causes "traffic congestion",and users must severely limit their transmission time. Toobtain privacy, voice scramblers are used. Health applica-tions generally utilize the emergency bands for emergencyservices such as ambulances, and the business barid foradministrative services. For rural applications, longdistances and hilly terrain often require the use of repeaterstations in addition to the base-station and mobile terminals.

Radio links offer flexibility in mobile applications and maybe substituted for the telephone system where it is notavailable. However, difficulties /nay be associated with the

*Two-way communication limited to one direction at a time.**A transceiver is a combination transmitter/receiver.

25

use of radio links. Distance, terrain, station location,or electrical noise may impair communication qualityand reliability. Also, the availability of radio channelsis limited in many areas because of the large number ofusers. The radio frequency spectrum is a limited resourceand it has been allocated largely on a first-come, first-served basis.

Long-range communicati3n is also possible via high fre-quency (HF) radio or by satellite communications. Forvery remote areas these me°-lods may be the only onesfeasible. HF radio has been used by the Navy in the ship-to-shore operation of an experimental narrowband tele-medicine link.9 Narrowband satellite communications linkshave been used in a similar fashion, both for militaryand non-military applications. High frequency radio isgenerally a less desirable transmission means thansatellite communication because of its greater suscepti-bility to noise*, the possibility that the communicationspath may be interrupted by fading**, and by the limitednumber of channels. However, HF radio costs are low.Because of the expense of building transmitting and receivingfacilities, narrowband satellite links generally have beenestablished only when other mechanisms are not available.The cost of such facilitle'S has dropped rapidly and time-of-use charges are going down. Most of these links arebeing integrated into the telephone network, rather thanbeing available as separate commercial services.

Education is the most common application of radio broadcastsystems within health applications. For point-to-pointradio communications, frequent applications include mobileemergency communications and mobile administrative support.The use of point-to-point radio links between fixed locationsappears to be effective and efficient only when telephoneservice is unavailable. For example, the National Centerfor Health Services Research sponsored the installation ofa radio link between a non-physician provider and hispreceptor physician in rural Idaho where telephone communi-cations were inadequate; the frequency of their contactsincreased appreciably.

*"Noise" is a term used to describe various type ofinterference, such as static.**"Fading" is a term used to describe the loss of radiosignal strength.

26

Broadband Telecommunication Systems

A broadband system Is one that is capable of carrying real-time video information of quality comparable to standardbroadcast television. The capacity of such a channel isapproximately 2,000 times as great as that of a narrowbandchannel. Inforl.ation bandwidths are available betweennarrowband and wideband. They are used primarily for datatransmission.

A broadband channel typically will carry a full-color videosignal associated audio channel signal and will havethe necessary "guard" bands to prevent interference betweensignals. Alternatively, this same broadband channel cancarry 1,200 narrowband channels simultaneously using theprocess of signal multiplexing. Private microwave systemsare allowed to combine multiple narrowband channels withthe video channel on one broadband transmission line. Thus,several voice channels, a data channel, a telemetry channel,and a facsimile or slow-scan channel can be carried simul-taneously with the video signal.

Transmission Means. The means for broadband transmissiontypically are limited to radio or cable.* Radio transmissionmay be either broadcast or point-to-point. Commercial andeducational television are broadcast signals radiated in arelatively uniform geographical pattern (i.e., omnidirection-ally) to all in the area who have receivers, such as televisionsets. Transmitters of this type are expensive to build andoperate, and it is very difficult to obtain a broadcastlicense because of the limited number of available channels.A group of special channels, called Instructional TelevisionFixed Service (ITFS), is available exclusively foreducational purposes. These systems operate omnidirectionallyin the broadcast mode and the radiated signal usually has arange of no more than ten miles.

Satellite communication systems are being used commercially torelay broadcast television signals and to interconnect localcable television systems. Satellite systems are feasiblefor the delivery of health-related educational programming tocommunities having cable television systems with satellitereceivers or to hospitals that wish to invest in a receivingsystem. Minimum capital costs for a broadband transmittingsystem are $50,000 at this time. Receive-only station costs

*The term "cable" refers to coaxial cable which has thecapability of carrying many channels of broadband informationsimultaneously.

27

are less than $5,000 per terminal. Operating cost. for abroadband satellite channel range trom $300 to $1,000per hour.

Microwave Radio. Fixed point-to-point communication havinga broad bandwidth is usually called "microwave radio",although there are other Hypes o transmission, such asradar and satellite, in the microwave region. As itsname implies, fixed point-to-point communication dependsupon a series of two-station connections. Depending uponthe line of sight between two locations, they ma, beseparated by three to fifty miles, with a parabolicantenna at each end focusing the radio signal into anarrow beam aimed at the receiving antenna. High buildingsor hilly terrain affects system routing, distances between.nd locations of terminals, and costs. Each transmitter-receiver pair makes up a "hop".

Because a large number of broadband channels require alarge amount of spectrum, new microwave radio assignmentshave steadily been moving up in frequency. At present,most microwave users in education, industry, and businessmust use frequencies in the 12 to 13 GHz band. Theallotted bandwidth in this band is 20 MHz which caneasily accommodate one video and many narrowband channelssimultaneously. Early common carrier (telephone company)assignments were at 2 GHz, a range where radio equipmentis easier and less expensive to manufacture.

Broadband Cable. Cable is used for short distances (e.g.,from studio, office, or control room to transmitter/antenna) and in areas where radio licenses are notavailable. Cable may be a cost-effective alternative tomicrowave radio for distances up to one or two miles,depending upon circumstances such as the availability ofspace to lay cables and the probability of the cable beingdamaged.

From a technological point-of-view, cable television systemscould be used for the entire range of health care communi-cation needs. However, since locations wishing tocommunicate often are not in the same community, and sincecable television systems are franchised on the basis ofpolitical jurisdictions, it is not likely that a cabletelevision system would connect all the points of a ruralhealth system. Cable systems in different communitiescould be used if they could be interconnected by otherbroadband transmission means and thereby made part of thesame network.

28

Networks

Transmission systems can be interconnected in variousconfigurations. Radio and wireline networks are discussedin the following paragraphs.

Radio. An example of a linear microwave radio network isshown in Figure 5. This one-way (Simplex) network has threetransmitters and three receivers. If it is to be made two-way, three additional transmitters and three additional-eceivers pointing in the opposite direction must be added.Tb same antennas and towers may be used for two-wayoperations.

In networks more complicated than the simple linear one, theswitching and the transmitter frequency determinations operatewith many practical restraints upon frequency selection.

AN.

TERMINAL ATRANSMITTEREND

REPEATER(RECEIVER/TRANSMITTER)

REPEATER(RECEIVER/TRANSMITTER/

Figure 5Linear Three-Hop Simplex Microwave Network

TERMINAL BRECEIVER END

29

Wireline. In the usual narrowband service, the telephonecompany resolves the technical problems involved in installa-tion and niaintenance of lines and switching. All of theengineering is performed for the customer, who purchasesonly a service. Telephone circuits are full-duplex(simultaneous two-way) and because of the structure of thenetwork, a series of swatches will allow a connectionbetween almost any two telephones.. A large proportion ofthe-investment of the telephone companies is in switchingapparatus.

It is very unlikely that an extensive video (broadband)switched network will come into existence as long aspresent wire technology is required for local loop .

distribution (i.e., from the switch to the customer'spremises). In the future, a broadband technology basedon transmission of signals via lasers and fibre optics islikely to emerge. However, the huge investment requiredfor implementation of this technology assures us that itwill be a very long time before videc transmission andswitching will be as ubiquitous as the present audiosystem.

30

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VIDEO

Facsimile, business typeSpecial facsimileSlow-scan television

Low resolutionMedium resolutionHigh resolution

Storage devicesStand-alone imagingFibre-optic devicesTelevision

Audio Instruments

Earlier the telephone system was described in terms of aswitched narrowband transmission system. This section refersto the telephone as a speech transducing instrument--onewhich on the transmitting end transforms speech into anelectrical signal and on the receiving end transforms anelectrical signal into speech. Devices and services oftenused as adjuncts to the telephone instrument are listed inTable 3.

Verbal communication via the telephone is highly interactiveand even permits some non-verbal information interchangethrough tone, phrasing, and voice nuances. The sophisti-cation of the participants and the precision of the medicalvocabulary can further enhance the effectiveness of speechcommunication. Verbal interchanges between providersoften can substitute for the transfer of visual information.

Administrative uses of the telephone instrument are frequentand familiar. Placing orders for equipment, makingarrangements for management activities, and discussingand clarifying record and billing information are typicalexamples.

Conference call and "hands-free" augmentations of thetelephone have been used effectively in educational activitiesof many kinds. Speech commun4cations can be augmented furtherby mailing textual materials or other visual aids prior toformal meetings. Telephone communication also has been usedquite effectively as the return link in educational activi-ties involving video communication from an instructor toremotely located students.

Similar capabilities can be attained with radio transmissionsystems. If the radio link is simultaneous two-way (full-

.

duplex), its use should be equivalent to the normal telephoneHowever, "push-to-talk" is the most common form'of point-to-point radio communication. This is a one-speaker-at-a-time

33

4

Table 3Audio (Speech) End-Instruments

NAME(1) Speaker phone

FUNCTIONAllows hands-free telephonecommunication and/or severalparticipants at one location

(2) Call-waiting Signals to talking user thatanother call is ringing

(3) Call-forwarding Automatically forwards callsto a pre-selected number;selected number may be changed

(4) Conferencing Allows users to make 3- or 4-party bridging connections withuse of operator

(5) Automatic answering Answers phone with tape re-corded message and recordsincoming message from caller

(6) Remote query Additional answering capabili-answering ty allows owner to retrieve

his messages(7) Tone paging Provides wearer with signal

(beeper) that he is wanted(8) Voice paging Provides wearer with "p to 10

second voice message(9) Mobile radio service Allows two-way radiotelephone

contact with other fixed ormobile sites

(10) Mobile radio system Same function as (9); in somecircumstances owning systemis only alternative

34

Available through local telephone companyAvailable for purchase through many local distributorsService available from local paging operatorsService available from local radio common carriers(See telephone company in yellow pages)

FEATURES/REMARKSAutomatically senses who is speakingand allows only that person to transmit;users take turns'speaking

Permits answering and/or holding ofincoming call*

May be part of Electronic Switching Services(ESS) package or devices; may be purchasedseparately for $300-$800**Part of ESS package

Many variations of this device providedifferent instructions and differentincoming messagesAuthorized _(coded) inquiry from a remotetelephone will play back the recordedincoming messagesUsually wearer calls his office or someother prearranged number for informationVoice pager often allows wearer to takere uird action without a phone callTwo-way radio may operate with thenormal dial-up telephone system

Private mobile radio is usuallylimited to users of own network

35

NAME TYPICAL SUPPLIERS1

(1) Speaker phone Telephone companies lease forapproximately $9/month;* purchasedde%;ice can be attached to anytelephone

(2) -Call-waiting Telephone company has special(3) Call-forwarding Electronic Sw34-ching Services(4) Conferencing (ESS) exchanges which allow these

three services;* may be orderedsingly or in combination; notavailable in all locations

(5) Automatic answering These are available for purchase(6) Remote query from many retail outlets;** see

answering the yellow pages of telephone book

(7) Tone paging (beeper) Usually purchased as a service;***hardware suppliers are GE,Lynchburg, VA and Bell & Howell,Waltham, MA

(8) Voice paging RCA Mobile C.:ommunic a tions

(9) Mobile radio service Service is usually paid for on amonthly basis plus a charge percall****

(10) Mobile radio systems Private systems available fromGeneral Electric, Lynchburg, VA

36

Available through-local telephone companyAvailable for purchase through many lcral distributorsService available from local paging operatorsService available from local radio common carriers(See telephone ccmpany in yellow pages)

COST($) PER TERMINAL

$30 to $100 purchased;$9 per month, leased

$5 to $15 per month forvarious combinations ofservice

$80 to $200$250 to $350

$21/month beeper rental$250 purchase

$26/month lease; complete pagingsystem costs $3,000 up

$50/month minimum

$5,000 and up for systemplus $1,800 per receiver

1NOTE: The listing of typical suppliers is not complete. Itdoes not imply endorsement of any popular product ormanufacturers. In general, it is not known whetherthese suppliers are prepared to give extensive appli-cations descriptions or to engage in detailed dis-cussions with persons attempting to become knowledgeablein their particular field of technology. For furthertnformation concerning telehealth technology orsuppliers, contact Friend Skinner, The MITRE Corporation,1820 Dolley Madison Boulevard, McLean, Virginia 22101.

37

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Table 4Telemetry End-Instruments

NAME FUNCTION FEATURES/REMARKS

(1) Telephonecoupler/modem

Allows coupling oftelemetry instrumen-tation to telephonesystem

(2) EKG(ECG)

Transmits electricalheart activity

Primarily used foro?erations where atemporary hookupmust be made be-tween instrumenta-tion of thetelephone system

Often combined withdefibrillator in aportable unit; plugsinto radio ortelephone lines

(3) ElectronicStethoscope

Permits transmissionof heart and cavitysounds over tele-phone lines

Has higher fre-quency responsethan conventionalstethoscope

(4) MiscellaneousTelemetry(EEG,Pulmonary,etc.)

Transmits anyphysiological in-formation thatexists as anelectrical signal

Any physiologicalsignals that havelow information ratesignals can be sentover narrowband tele-phone lines

1 NOTE: The listing of typical suppliers is not complete.It does not imply endorsement of any popularproduct or manufacturers. In general, it is not knownwhether these suppliers are prepared to give extensiveapplications descriptions or to engage in detaileddiscussions with persons attempting to become knowledge-able in their particular field of technology. Forfurther information concerning telehealth technologyor suppliers, contact Friend Skinner, The Mitre Corporation,1820 Dolley Madison Boulevard, McLean, Virginia 22101.

40

TYPICAL SUPPLIERS' COST(S) PER TERMINAL

EMR, Sarasota, FL is a compo-nent supplier for originalequipment manufacturers

$200

Datascope, Paramus, NJMarquette Electronics,Milwaukee, WI

$4 , 500

Heart Sound Reproductions, $150Tomball, TX

Hewlett/Packard Medical Not applicableElectronics, Waltham, MA

41

Table 5Data/Record End-Instruments

NAME FUNCTION

(1) Keyboardterminal

Acts as alphanumericdata input device fora computer or communi-cations system

(2) Cathoderay tube(CRT)

Displays alphanumericdata on screen

FEATURES/REMARKS

Usually combinedwith a displayor hard-copycapability

Many displaysare generated bykeyboard input;are "smart" or"dumb" dependingupon whether theycan stand aloneor require ahost computer;usually areinteractive

(3) Printer Printed paper outputfor permanent alpha-numeric record oftraAsactions

Printers are peri-pheralS thatsimply record thedata; they areoften combinedwith input de-vices (keyboards)and CRTdisplays

INOTE: The listing of typical suppliers is not complete.It does not imply endorsement of any popularproduct or manufacturers. In general, it is nozknown whether these suppliers are prepared to giveextensive applications descriptions or to engage indetailed discussions with persons attempting tobecome knowledgeable in their particular field oftechnology. For further information concerningtelehealth technology or suppliers, contact theMITRE Corporation, 1820 Dolley Madison Boulevard,McLean, Virginia 22101.

42

TYPICAL SUPPLIERS' COST($) PER TERMINAL

TeleType, Skokie, ILTexas Instruments, Houston,TX

$500 to $1200; bare key-boE-rd less than $100 inlarge quantities

Datapoint, San Antonio, TXInfoton, Burlington, MAPerkin-Elmer, Tinton Falls,NJ

$800 to $5,3C

Digital Equipment, Maynard, MATexas Instruments, Houston, TXTeleType, Skokie, IL

$1,000 to $5,000

43

Teletype (Alphanumeric) Data Transmission. Most teletypemachines are no longer the clanking mechanical devicesof the past. New keyboard-input, printer-output devicesare faster and quieter. The newer devices typicallytransmit at a sel stable 10-, 15-, or 30-words-per-minuterate over a voi,:e-grade, narrowband line. The samemachine is used for both transmitting and receiving andalso can make a copy of what it is transmitting. Somemachines punch a paper tape, some record on magnetic tapefor later transmission, and others print. If a printec'record is not required, then a TV-like display may beutilized. The text can be viewed on a cathode-ray-tubeterminal at both transmitting and receiving ends, and alimited number of lines of text may be stored and retrieved.If a telehealth system is configured to store and searchrecords using a computer, these data communications devicesbecome important end-instruments.

A variety of computer applications are available in the healthfield. Computers may be used locally or remotely to supportpatient care as well as administrative functions. Adminis-trative services are widely available through commercialcomputer time-sharing services, associations or groups ofhospitals, and computer facility sharing. Applicationsclu-ie computerized billing and accounting services15,production of financial reports, and processing and prepara-tion of medical and administrative records for managementpurposes. Complete comnuterized medical record systems havebeen developed for hospital applications and group practices,and are likely to become available shortly on an economicallyattrictive basis16, 17 even for small practices.

Computer systems may also serve educational purposes inrural areas.18 Computer-assisted instruction is currentlyused in training new physicians and in providing continuingeducation. Data communications are essential for briningthese diverse capabilities to rural health systems whichcannot afford stand-alone computer facilities.

Image-Type Data Transmission. Data and records also may betransmitted by means of facsimile (FAX) equipment. Thesede.ices transmit pictures from one location to another overnarrowband links. Facsimile is versaile and if the traffic(number of individual documents) is -aarly low, it can beutilized effectively for one transmission of pictures,written records, signatures, and charts such aL; EKG tracings.Most systems use the same terminal for transmitting (input)and receiving (output). This type of terminal is called a"transceiver". It requires a narrowband communication line,

although some machines are designt_ for faster or moredetailed picture transmission over somewhat greater band-width lines.

The photograph or printed document to be transmitted isscanned, line-by-line, in a manner similar to a televisionscan. Since the bandwidth of the communications channeldoes not permit the picture elements to be transmitted ata high rate, it takes from 4 to 16 minutes to transmit asingle page. A direct relationship usually exists betweendegree of resolution and transmission time. Moderateresolution can be obtained with six-minute transmissiontimes.

A new type of facsimile has become available recently whichwill transmit a medium-resolution page of text in 30seconds. This is ciccomplished by restricting the image toneto either black or white; no gray scale is possible. Withhigh quality FAX machines, seven gray-levels are discernibleand over 90 lines per inch are resolvable. Table 6 providesinformation regarding facsimile transceivers and other image -type devices.

High-resolution facsimilc' equipment that utilizes lasersfor scanning the material to be transmitted is comIrerciallyavailable. Deve.Lopmental configurations can proviee vari-able resolution of up to 250 picture elementJ; per inch over

4 inch length and 1,000 picture elements per inch overInches. Such systems use dry-silver film which is

developed on-line to produce ready-to-usE_ output includingx-rays of diagnostic quality. Although not yet commerciallyavailable, these developmental systems may become competitivein the future, particularly where extremely high resolutionis required. These devices have been designed for datatransmission at 56,000 bits per second, which is considerablyhigher than can be transmitted over normal telephone lines,but considerably lower than video transmission rates.

Video Instruments

End-instruments that capture, transmit, and display videoinformation take a wide variety of forms. However, all videoinstruments involve the use of some type of camera.Facsimile instruments, discussed above, could have beenconsidered as video equipment because they transmit animage which has been taken with a photographic camera.However, this section will stress the transmission of videoinformation in which there is no intermediate stage toproduce a hard copy of the video image. Three types of videoend-instrument 7ystems will be discussed--"normal" or

45

5

Table 6Video End-Instruments

NAME FUNCTION

(1) Facsimile (standard) Transmit/receive hard-copy

(2) Facsimile (hi speed/hi-resolution)

Transmit/receive hard-copy

(3) Slow-scan television(SSTV)(a) low-resolution(b) medium-resolution

(c) high-resolution

Transmit/receive videoimage over telephone lines

Transmit/receive videoimage over telephone lines

Transmit/receive videoimage over telephone lines

(4) Stand-alone imaging Provid(± soft-copy (display)imaging manipulation andenhancement capability

(5) Storage Devices Store video images forlater zet_Lieval and display

(6) 21bre-optics devices Gather optILal images froootherwise inaccessibleplaces such as body ori-fices. In conjunction withTV or slow scan transmission

(7) Television To transmit/receive movingimages electronically

'NOTE:

46

The listing of typical suppliers is not complete.It does not imply endorsement of any popular productor manufacturers. In general, it is not knownwhether these suppliers are prepared to give exten-sive applications descriptions or to engage indetailed discussions with persons attempting tobecome knowledgeable in their particular field oftechnology. For further information concerningtelehealth technology or suppliers, con.-_-act Friend Skinner_The MITRE Corporation, 1820 Dolley Madison Boulevard,McLean, Virginia 22101.

FEATURES/REMARKS

64 or 96 lines per inch resolution; limited gray-scale reproduction; 4 to 6-minute transmission time

Up to 400 lines/inch resolution; gray scale limitedonly by quality of print material; 30 second to 16minute/page transmission time

Resolution approximately 128x128 picture elementswith 16 levels

Resolution 256x512 pixels with 64 or 256 gray levels

Resolution 1024x1024 pixels with 246 to 1024 graylevels

Digital storage and image processing, pseudo color,overlays, cursors, etc.

Instant recall--magnetic disc; delayed recall-magnetictape

Optical input must be coupled to TV or SSTV system

Requires camera, monitor, controls and coaxial cableor microwave radio transmission (Monochrome or Color TV)

47

NAME TYPICAL SUPPLIERS)(1) Facsimile (standard) Xerox, Rochester, New York

3M, Minneapolis, Minnesota

(2) Facsimile (hi speed/hi-resolution)

Muirhead, Mountainside, New JerseyHarris Corp., Melbourne, FloridaRapidfax, Fairfield, Connecticut

(3) Slow-scan television(SSTV)(a) low-resolution

Robot Research, San Diego,California

(b) medium-resolution Colorado Video Inc. Boulder, CONEC America, Glenview, Illinois

(c) high-resolution None commercially available

(4) Stand-alone imaging Comtal, Pasadena, CaliforniaRamtek, Sunnyvale, CaliforniaGrinnell, Santa Clara, California

(5) Storage devices Arvin/Echo, Mt. View, CaliforniaPanasonic,* Sony,* JVC*

(6) Fibre-optics devices Olympus, New Hyde Park, New YorkApplied Fibreoptics, Southbridge,Massachusetts

Fujinon Optical, Scarsdale, NewYork

(7) Television System must be custom engineered

*Video tape recorders are available from local distributors.Audio tape recorders cL..n store SSTV images; cost, $100 to$250.

48

COST($) PER TERMINAL

$1,750 to $3,000

$8,000 to $18,000

$1,500

$15,000 to $17,500

$60,000 and up

$8,000 to $30,000

$2,000 to $10,000$200 to $10,000

$5,000 to $10,000

$30,000 to $300,000and up

1NOTE: The listing of typical suppliers is not complete.

It does not imply endorsement of any popular productor manufacturers. In general, it is not knownwhether these suppliers are prepared to give el,:cen-sive applications descriptions or to engage isdetailed discussions with persons attempting tobecome knowledgeable in their particular field oftechnology. For further information concerningtelehealth technology or suppliers, contact Friend Skinner,The MITRE Corporation, 1820 Dolley Madison Boulevard,McLean, Virginia 22101.

6 J

49

"standard NTSC"* television, slow-scan television (SSTV),and special viewing instruments based on fibre-optictechniques. Table 6 lists several video end-instruments.

The Video Camera. A television (video) camera is requiredfor all video systems. It is a complicated device and maybe quite expensive. The camera electronically scans anoptically-produced image and dissects it, element-by-elementand line-by-line. The resulting electrical signal is trans -mitted and the original optical signal is reproduced on thereceiver's picture tube using a moving electron beam whichexcites a light-producing phosphor spot. The spot isrefreshed 30 times a second and the human eye "remembers"each illuminated spot between refresh cycles.

There are several pitfalls for the user of a televisioncamera. Although most modern video cameras auto=ticallyadjust themselves for average lighting, lighting remains amajor problem in obtaining good images. Use of the properlenses, including zoom lenses, also is an importantconsideration. MITRE has expended significant effort inits Telehealth Laboratory in determining how to achieve thehighest quality and the most useful video images for tele-health applications.

Monochrome (black-and-white) television is complex, but theaddition of color multiplies the technical problemssignificantly. Balancing of colors is extremely dependentupon lighting, and nonprofessional camera work usually pro-duces an inferior image quality. For medical diagnosis,there are many unanswered questions about the usefulness ofcolor. The limited research experience on the effectivenessof color in remote medical consultation/diagnosis has beenin the field cp:_ dermatology. These results have indicatedthat the absence of color does not affect the accuracy ofdiagnosis, but does increase the time required to make adiagnosis.19

*NWC stands for National Television Standards Committee.The picture frame consists of two interlaced fields havinga total of 525 horizontal lines. Of these, 480 lines arevis_.--)le on the TV screen. The horizontal resolution isapproximately the same as the vertical resolution.

50

Ancillary camera equipment at the input end consists oflights, lenses, mounts, camera controls, and switches.LightIng may be critical for certain views, but most black-and-white cameras operate quite adequately with simple roomillumination from fluorescent lights. Auxiliary lightingusing table top lamps or a fibreoptics-directed cold lightsource often- is helpful.

In MITRE's experience a small zoom lens with a 6:1 zoomratio generally has been adequate for enlarging the size ofthe image to be transmitted. This zoom lens is sometimesused with a set of "close-up" lenses, which allow even closerviews and greater magnification (e.g., six inches away andsix times real-size images for dermatological or throatexaminations). Magnification of a 3-inch by 4-inch portionof an x-ray to full monitor size provides moderately highresolution.

NTSC Standard - Quality Television. The maximum resolutioncapability of a frame of commercial (NTSC) monochrometelevision is approximately 370 lines in the verticaldirection. Achievable resolution with. commercial productsis between 325 and 350 lines, but typically it is less than300 lines. Horizontal resolution is comparable. Camera andmonitor resolution in excess of 800 lines per picture isreadily available for closed-circuit applications; hoer,such high resolution pictures cannot be transmitted direr astandard television channel. The transmission medidtisthe limiting factor.

.The suitability of video for telehealth applicaLion 'varieswith the resolution and gray-scale requirements of theapplication, as well as with the 1-,uirements for imagingtechniques in an operational setting.

Gray-scale capability refers to the number of shades of grayand to the number of gray levels. The number of shades ofgray refers to the range, from black to white, which can berepresented by a system. The NTSC standard range is dividedinto 10 shades, the relative increase or decrease from oneadjacent shade to another being related logarithmically. Thenumber of gray levels indicates the number of discrete stepswithin the range of black to white for systems that use digi-tal storage. Analog systems are indicated as having contin-uous gray levels, distinguishability being limited bysystem noise.

51

The gray-scale range. of a standard monochrome televisionimage is lower than the range of photographic film andhigher than that of a photographic print. In general,however, the gray-scale limitatis of NTSC television arenot significant in actual use and the average person cannotdetect any gray-scale anomalies under normal viewingconditions.

Presently, the most accepted area for video communicationsis that of education. The resolution and gray-scalecapabilities of commercial television are more than adequatefor most educational purposes. However, the limitations oneducational uses of video communications stem largely fromthe high costs of video programming and the high cost oftransmission systems required by television.

Classroom lecture situations can be handled quite effectivelyby means of video transmissions. Although such a format mayprovide a "dull" presentation, no particular operationaldifficulties generally ensue. When the educational formatincludes teleconferencing or similar group situations,multiple camera techniques are generally required, and thecoordination of natural interactions in the video presenta-tion becomes increasingly difficult. Complex and expensivestudio set-ups, program direction, and control staffingmay be required.

There are numerous examples of the use of live television forhealth education purposes. The Dartmouth INTERACT System,3the Massachusetts General Hospital System,' and the OhioMedical Microwave Network' --e three of many successful usesof live television for health education. These systems usepoint-to-point microwave radio transmission for the televisionsignal.

The NASA ATS-6 satellite was used for a number of experimentsin primary care administrative, and educational applicationsof television. 26 Notable among these was the WAMI (Washington,Alaska, Montana, Idaho) project, which conducted two-way livebroadcasts between Alaska and the University of WashingtonMedical School. Veterans Administration Hospitals inAppalachia also have utilized the ATS-6 satellite foreducation and teleconsultation.21 The forthcoming CTS(Communication Technology Satellite) system will include anumber of additional health educational experiments usinglive television and satellite transmissio,3,,to link separatesites in a dispersed educational network.--

52

6

Many medical and educational institutions have establishedclosed circuit television systems to facilitate healtheducation and training. Television also has proved to be aneffective medical tool in a wide variety of diagnostic andconsultation situations. Notable successes have been demon-strated in dermatology, speech therapy, psychiatry, andnurse-anesthetist supervision. The Handbook Appendix containsdescriptions of a large number of television projects.

Slow-Scan Television (SSTV)

combined factors of consultation needs and technologycosts make the e:Id-instrument technology referred to as slow-sc:n television worthy of consideration for telehealthapplications. The single greatest impediment to the use ofstandard television in rural health systems is the cost ofestablishing and operating a broadband channel having thecapability to transmit continuous video information.Moreover, investigations.of the medical use of video informa-tion indicate that most information of interest may beobtained by examining several non-sequential frames of videoinformation.4

Principles. The concept of slow-scan television (SSTV) comesfrom a rather simple notion. A single frame of video containsa huge amount of information. Standard, moving televisionrequires a very large amount of bandwidth to transmit eachframe's information in a very short period of time (1/30th ofa second). However, a single video frame can be transmittedusing the very small bandwidth of a telephone channel if aconsiderably longer period of time (approximately 30 to 90seconds) is allowed. This concept is embodied in the equipmentreferred to as slow-scan television. Table 6 contains alisting of slow-scan hardware, costs, and suppliers.

A slow-scan television system consists of the eight majorcomponent f; shown in Figure 6. A video camera is used tocapture the view of interest in the same manner as it isused for standard television. The frame of video is rapidly(1/30 second) stored in a video frame storage device. Fromthe frame-storage device, the video is slowly (60 to 90seconds) read out by the scan converter at a rate that canbe transmitted over a telephone channel. The modulatoraccepts this signal and transmits it over the telephone lineto the receiving end.

At the receiver, the demodulator extracts the slowly varyingelectrical signal and passes it to the video scan converterwhich assembles the video frame of information for the frame

53

_4-

III

CAMERAVIDEO

FAST

TAN

0 000 0MONITOR

FASTREFRESH

FRAMESTORAGE

SCANCONVERTER

11

TRANSMITTING TERMINAL

FRAMESTORAGE

SCANCONVERTER

MODULATOR

SLOW

TELEPHONELINK

DE-MODULATOR

SLOW SLOW

RECEIVING TERMINAL

Figure 6Slow-Scan Television Functional Diagram

storage unit. The full video frame then rapidly (within1/30 second) and repeatedly refreshes a standard televisionmonitor.

Capabilities. A SSTV system operates on a principle verysimilar to the facsimile system, using a sequential scanningprocess to dissect and later assemble an image. However,unlike facsimile, it is not limited to transmission of ahard-copy record. The slow-scan hardware accepts an elec-tronic image from a video camera and stores the frame forthe length of time necessary to transmit the electricalsignal over the narrowband communications link. Typically,it takes from 30 to 90 seconds to transmit one frame. Theexact time depends upon the image resolution and the gray-scale gradations required by the user. If more than oneframe is to be stored at either end of the system, addi-tional memory may be incorporated to retain frames foras long as it is desired.

The comparison of presently available SSTV and FAX systemshinges primarily on operating features (soft-copy vs. hard-, .1, input and output, resolution (FAX has approximately1 the resolution), gray-scale range (any hard-copy hasa each more limited tonal range), and transmission time(SSTV is two to four times faster per image).

Resolution differences between slow-scan and facsimile end-instruments may be somewhat misleading. A zoom lens on Is'SSTV video camera can effectivz.ly increase the resolutio.of transmitted information by utilizing the inherenttion of the camera on a smaller area of interest, such s5 aportion of an x-ray. This approach is not possible withexisting facsimile equipment. The gray-scale limitationsof facsimile equipment are largely due to the print materialused for the hard-copy output. Work has been done using afilm medium for the hard-copy and this significantly enhancesthe gray-scale reproduction capability for x-ray use.

The current cost of a high-quality, medium-resolution slow-scan transceiver terminal is between $15,000 and $19,000.The cost of a standard facsimile transceiver is approximately$3,000. The cost of a high-quality facsimile terminal is$8,000 for a transmitter and up to $18,000 for a receiver.Transmission of very high-quality facsimile could increasethe transmission time by a factor of four to six compared tostandard facsimile.

The very limited research done to date comparing slow-scantelevision to live television tends to show no significantdifference in the utility of live television with respectto remote diagnosis, if motion is not a significant element

55

in the diagnosis. Furthermore since slow-scan televisionuses the dial-up telephone system for transmission, it offersgreater flexibility than live television which must utilizepoint-to-point transmission systems. In a system based oncompatible slow-scan television transceivers, any terminalcan interact with any other terminal, over the telephone,as the need arises.

Some of the capabilities of currently available slow-scantelevision systems are shown in Table 7. This table indicatesthe characteristics of various models, including resolution,gray-scale, storage mode, transmission time, and approximatecost.

Applications. In patient-care applications, slow-scan tele-vision provides a logical mechanism for transmission of x-rays, pathology slides, and similar fixed-frame visual infor-mation, as well as patient views. Present systems use black-and-white transmission, with one exception.* Thc absence ofcolor provides no limitation on x-ray transmission, but mayprove somewhat limiting for pathology applications which arehighly dependent upon (artificial) color information fromstaining. To date, there are indications that color maynot be essential even in pathology studies where it has be-come the standard presentation format. However, no systematicinvestigation of the effect of color on pathology diagnosishas been attempted.

There have been several applications of slow-scan televisionfor x-ray transmission. A two-year, NCHSR-sponsored programin Nebraska involved the use of developmental slow-scan equip-ment for the transmission of x-rays from Broken Bow to Omahain order to obtain radiology consultation services. Theresults indicated that teleconsultation, even with degradedtransmission, was more satisfactory than local interpretationby non-radiologists.23 A Navy program has successfullyutilized a moderate resolution slow-scan television system:o assist in medical consultation between non-medical per-sonnel on-board ship and medical personnel on shore.9

*A digital, full-color, slow-scan television system has beenbuilt by Nippon Electric Company (NEC). It costs approxi-mately S21,500 per terminal for the scan converter and single-image storage memory. This cost does not include the sig-nificant expense of color cameras and monitors.

Table 7Summary of Some Slow-Scan

and TV Devices

STORAGE MOUE

PICTURE ELEMENTSVERTICAL x HORIZONTAL(Pixels)

TRANSCEIVERSColorado Video Digital (RAM)Model 280NIPPON Electric Digital (RAM)754 TVSRohnt PLTV 530 Digital (RAM)RCA Video Voice(5)(6) Storage tube

WestinghouseMedim II(8)

Disc ordigital

256x256 (fast)256:612 (slow)262x226

123x128(4)480x256 (fast)480x512 (slow)480x540

TRANSMITTERSColorado Videc Digi -al (RAM) 256x256 0.260B(9) 256x512Robot PLTV 520 Digital (RAM) 128x128

RECEIVERSColorado Video 275 Digital (RAM) 256x256 (fast)

256x512 (slow)Robot PLTV 510 Digital (RAM) 128x128

FRAME FREEZERS(I0)Hitachi MS-100 Magnetic disc 240x512(1 TV field)Colorado Video MS-200 Magnetic disc 480x512 N.

(1 TV frame)Hughes 639H Storage Tube 810x1080

Princeton Elec- Storage Tube 810x1080

ArvinPEP-400

Arvin/Echo VDR7IR Magnetic disc 480x540(200 TV frames)VAS (100 TV Frames) Magnetic disc -60x540

(1) Cameras and monitors limit the range of gray from blackto white to 8 or 9 shades for al: system

(2) Assumes 300 to 3,000 Hertz bandwidth telephone lines(3) NEC uses delta or differential gray scale encoding from

bit to bit too obtain approximately 8-bit gray scale(4) Robot systems have a square, image format (i.e., 1:1 ver-

tical =o horizontal ratio; all other systems have 3:4vertical to horizontal ratio.)

(5) RCA Video Voice available only as surplus equipment; nolonger supported by manufacturer

57

GRAY SCALE(1)(Black to WhiteQuantization)

64 steps256 steps8 bits effe _ive(4 bits

(3)data)

16 steps (4 pits)Continuous (analog) (7)limited only by noise10 bits, limited bynoise (7.

64 or 256 steps(6 or 8 bits)16 steps (4 bits)

64 steps (6 bits)256 steps (8 bits)16 steps (4 bits

TRANSMIT TIME(2)(seconds/frame)

APPROXIMATECOST ($)

34 seconds $16,00078 seconds30 seconds $17,500

8 seconds $ 1,69530 seconds $ 1,50055 sr -lnd-3(5)120 se......ads N/A

34 or 78 $ 1,500 (6 bit)seconds $ 2,000 (8 bit)

8 seconds $ 1,545

34 seconds $12,000 (6 bit)78 seccnds $14,000 (8 bit)8 seconds $ 1,395

Continuous (analog,limited only by noise

Continuous (analog)limited only by noise

Continuous (analog)limited only by noise

Cone:inucus (analog)limited only by noise

Continuous (analog)limited cnly by noise

Continuous (analog)limited only by noise

:T/A

N/A

N/A

N/A

N/A

Nh.

Not commerciallyavailable$ 2,000

$ 4,500

$ 4,000

$10,000

$ 9,000

c:

(6) Camera subject must be stationary for high-resolutiori transm.. -on(7) Continuous or analog signals have electrical "noise" superimpL-ed

on the information signal; in an image, noise looks like the "snow"seen on a television set when a weak signal is received; it mayvary from the barely perceptible to the extremely obvious

(Ft) Westinghouse equipment still undergoing development; specificationsubject to change or modification::

(9) CVI 2603 must haVe stationary image or use a frame freezer to stopimage m6vement during transmission

(10) These devices are used for auxiliary storage of video frames; theymust be used with a slow-scan transmitter or receiver fortelecommunications

58

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Slow -sera television already has been used successfully foreducational purposes. Courses have been given at NorthwesternUniversity to demonstrate and develop educational techniquesusing this medium. Slow-scan television was used like aremote viewgraph or slide projector and thus did not requiresignificant revision or development of educational materials.The approach was also acceptable to students. They regardedslow-scan television as providing the same effective capabi-lity as closed circuit television-28

Despite the considerable advantages offered by slow-scantelevision, operational experience with this type of equipmentis relatively limited in the medical field. Resolution andgray-scale limitations will undoubtedly restrict its utilityin some applications. However, its demonstrated capabilities;its continually improving cost and quality ch,-..7cteristics,because of new solid-state and digital techniques; and itsutilization of the switched telephone network clearly pointto slow-scan's importance as a potentially cost/effectiveteiehtalth technology.

Patient-viewing Video Devices

"Patient-viewing video device" is a term used to describe anequipment class tha- permits the viewing of body orificesusing fibr-aqztic techniques. Cold light is supplied forillumination -and an image is brought to the camera via abundle of many flexible ontical fibers. Such devices arerelated to the patient-viewing microscope and similar diagnos-tic instruments that permit interior body views. The NASA/HEWPapago Program, STARPAHC, uses a patient-viewing microscopecoupled to a live video transmission system, in a mobileclinic environment.1 There are initial indications that suchtechnology could facilitate remote physician cc iultationsto rural clinics employing non-physician providers. This isparticularly the case for consultation in conjunction withupper respiratory infections and ear problems.

Standard fibrescopes, which are hand-held viewing systemswith flexible fibreoptic probes, can be coupled to a standardendoscope, otoscope, or nasal speculum for a less expensiveand less complex body-orifice viewing capability. Since theimages developed by such devices are of interest primarilyas single frames of information, these devices appear to behighly suited for use with slow-scan television. To date,test results have been less than satisfactory because ofimage-quality problems- Current cost estimates begin at$6,000 including the necessary video camera coupling.

60

P4

Examples of End-Instrument Configurations

There are a very large "number of potentially viable combi-nations of equipment and techniques. In this section,selected combinations are illustrated in a very simplifiedform. These illustrations are intended to show how amore complLx information system can' be des_gned from thesimple buildir- blocks previc.,Isly described.

A simple one-way video, two-way audio system is shown inFigure 7. This combination has often been used in tele-health systems.

VIDEOCAMERA

1°E1(.50 rTELEPHONEINSTRUMENT

V iiI3E0MONITOR

0 000 0TELEPHONEINSTRUMENT

Figure 7Video and Audio System

ONE-WAYVIDEO SUBSYSTEM

TWO-WAYAUDIOSUBSYSTEM

61

The video subsystem ,__onsists of an Input device (camera),a transmission line (coaxial cable or microwave radio link,f_11ustrated by SS ), and a display device such as a videomonitor. The audio subsystem may utilize two telephonessoeakerphones may be used for hands-free operation) ; or a

r rophone and speaker combination (not shown) may be useda- each end. Both telephone and microphone speaker audiosystems have been ured successfully in existing telehealthapplications.

A tape recorder, although not shown in Figure 7, may bR usedas a storage device at either the transmitting or receivingend to record either audio data alone or audio and videodata. The extent of recorded information within a telehealthsystem depends upon the wishes of the users.

Figure. 8 illustrates character-oriented (alphanumeric) devices.For record or hard-copy, commonly used devices arc an inputk;-vocard and an output printer. Although the figure showsone-way (simplex) devices, it is far more common for each-end-instrument to have both a transmit and receive capability.If this is the case, the devices must take turns transmittingand receiving (half-duplex). Data also may be sent andreceived over narrowband lines from a computer. The outputterminal may produce hard-copy or soft-copy such as a CRTdisplay. Data terminals are becoming extremely sophi-,:icatedin their storage and computing capabilities, as well as intheir processing. The cost of computers and "smart"microprocessor-based terminals is decreasing rapidly. Infuture publications,MITRE will provide considerably more infor-mation concerning computer technology applications in ruralhealth systems.

KEYBOARD

INPUT

INPUT /OUTPUTUSER TERMINAL

PRINI-ER

RECORD OR

If HARD COPYOUTPUT

TIME-SHAREDCOMPUTER

KEYBOARD

Figure 8Data-Oriented End-instruments

62

The telephone, an audio- end instrument, is shown in asimplified system form in Figure 9.

TELEPHONEEND-INSTRUMENT

ADJUNCT ADJUNCTTELEPHONE TELEPHONEDEVICE DEVICE

TELEPHONEEND-INSTRU4IENT

Figure 9Two-Way Audio System

The telephone instrument may be couplc4 with a wide varietyof adjunctive devices, a number of which are described inSection 4. These devices do not modify the basic speechcommunication function, but provide for interconnection,switching, storage, and extension of the telephone end-instrument.

The radiotelephone will provide a very similar function,whether it is a private system or a service provided bycommon carrier. The major exception is,that radio communica-tion is one-way-at-a-time, and also some of the telephoneadjunct services are not available.

The telephone instrument also may by used as a transmit orreceive device for telemetry. In Figure 10 the telephoneinstruments are used to couple telemetry end-instrumentswith a narrowband telephone link.

EKG

TELEMETRY ACOUSTICINSTRUMENT COUPLER

TELEPHONErf---L_C*4*"E

TELEPHONE ACOUSTIC TELEMETRYCOUPLER RECORDER

Figure 10Acoustic-Coupled Telemetry

1

63

The system illustrated in Figure 10 shows three end-instru-mentsthe telemetry instrument, the acoustic coupler, andthe telephone instrument. Each of these performs a differentfunction, however, ana this seemingly roundabout way of trans-mitting telemetry is really quite cost-effective in terms ofsimple, reproducible interfacing between pick-up and thecommunications link.

Figure 11 shows facsimile and slow-scan, two kinds of end-instruments that allow communication of visual informationover narrowband transmission lines. Facsimile requireshard-copy input and produces hard-copy output. Most modelsare combined transmitters and receivers (transceivers). How-ever, new high-speed, high-picture-quality models are eithertransmitters or receivers, not transceivers. Regardless ofthe model, facsimile systems operate in a half-duplex (one-way at a time) mode.

slow-scan system of image transmission may be one-way, assaown in Figure 11 or two-way. If the subject is motionless(e.g., a photograph or an x-ray), storage at the transmitterend is not required. However, there must be storage of thecomplete picture at the receiving end. The scan-converterat the transmitter end accepts a standard video camera signalas input and produces a narrowband signal as output to thetelephone line. The scan-converter at the receiving endfunctions in exactly the reverse manner.

New technology in the area of picture element storage, by farthe most expensive part of the slow-scan system, may bringabout a marked reduction in storage costs. Devices are beingconsidered to interface video camera input to a system thatprovides a facsimile-like hard-copy output. However, suchcombinations are not yet commercially available.

Figure 12 illustrates three systems that use different medical-specific end-instruments as input to a video camera. Theinputs are a trinocular laboratory microscope, a fibreopticprobe (with appropriate speculum attached), and a fibreopticcoupled patient-viewing microscope (PVM). The video outputfrom the camera may be transmitted in real-time on a broad-band communication link, or a single frame of the video maybe fed into a slow-scan television system and transmittedslowly over a narrowband channel. Normally there would bea two-way audio link associated with each video system. Thesethree systems can transmit images that cannot be readilyviewed by the unaided eye. However, their utility has notbeen investigated outside the laboratory.

64

FAX

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MMI=MMI alVIDEO

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Figure 12Some Medical-Specific End-instrument Systems

This section and the previous one have discussed t'e trans-mission systems and end-instruments that are the technicalcomponents of telehealth systems. Their characteristics,advantages, disadvantages, and potential have been describedin relation to the functional application areas of patientcare, administration, and education. The following sectiondiscusses selecting and assembling a zelehealth system fromamong these components and attempts to provide guidance indetermining whether or not a telehealth approach is appro-priate or feasible in a.particular operational situation.66

7 .1

6 TELEHEALTH SYSTEM IMPLEMENTATION

The previous sections described telehealth technolc.gy and itsapplication in patient care, education, z.nd administration.The purpose of these sections was to indicate what could bedone. The purpose of this section is to deal with whatshcuid be done -- in other words, deeding whether telehealthapproaches would help to strengthen a particular health caresystem.

In considering the question of telecommunications' advantagesin rural health care delivery, telehealth system design fac-tors must be addressed simultaneously. One must first assessthe structure, needs, and problems of a health care systemand then consider design alternatives in determining whethertelehealth appears to be a sufficiently attractive solutioncompared to conventional approaches.

Ideally, specific telehealth systems would be defined asappropriate for particular health care system models. However,as enticing as "standard" system design might be, theyprobably will not work in practice. The unique needs ofdifferent settings and situations, and the values placed onspecific capabilities, make the use of "canned" solutionsinappropriate.

Improving health care delivery in isolated, low-densityagricultural areas is very different from improving healthcare delivery in rural vacation areas with great seasonalswings in population. Some health care systems may be con-cerned with providing basic preventive and acute care serv-ices because they do not currently have such services; othersmay want to focus on the incorporation of specialists' serv-ices in areas having only a primary care capability.

This section concentrates on the process of formulating tele-health alternatives and assessing their desirability forindividual situations.

67

Defining and Evaluating the Telehealth Alternatives

The process of defining and evaluating telehealth alternativesmay be considered in terms of the five-stage process illus-trated in --;igure 13. This process need not be rigidly ad-hered to, but each stage s ould be given conscious considera-tion. The characteristics f a particular situation maypermit simplification of some stap.c.s.

Stage I: Determination of System Requirements

The initial stage in determining the desirability of a tele-health system considers wha-- the potential system must be ableto do, and how well it has to do it. Three types of require-ments must be defined: functonal, structural, and performance.

Functional Requirements. Defining functional requirementsis a matter of determining what types of clinical, adminis-trative, and educational. applications will be performed bya telehealth system. If physician-based practice wantstelehealth support for specialist consultations, then thetypes of specialists' set-J.:Es (e.g., radiology, cariology,pathology) should be identified along with tie types ofspecialty cases for which support is desired. This approachis required in order to define what type of information wouldbe transmitted over the communication links.

Structural Requirements. Structural requilments refer tothe number and location of participants in the telehealthnetwork. If a non-physician provider-staffed rural clinicis to'be linked with a physician's office, the network mayconsists of two points the rural clinic and the physician'soffice. In a slightly more complex system, the network mayconsist of a clinic and several physicians offices and/orhospital locations. The network structure must be identifiedto determine how many links will be needed and what functions(information transfers) are associated with each of the linksin the network.

In the case of networks of hospitals, different locationswithin a hospital should be identified. Situations mightarise when consultations are needed from physicians inseveral departments of a hospital. This would r.,'quire in-formation transfers to individual departments in one hospitaland perhaps to consultants located at another hospital. Thesestructural considerations are important in estimating thecosts and operating complexities of a potential telehealthsystem.

Performance Requirements. Performance requirements usuallyare stated in terms of accuracy, response time, error rate,68

STAGE I:DETERMINATION OFSYSTEMREQUIREMENTS

1

STAGE II:DETERMINATION OFSYSTEM CONSTRAINTS

STAGEDETERMINATIONOF SYSTEMALTERNATIVES

STAGE IV:COMPARISON OFSYSTEMALTERNATIVES

STAGE V:SiTLECTIONOF SYSTEM

Figure 13Determining the Desirability of a Telehealth Approach

69

resolution, and speed of image transmission. The minimumcapability requirements for each link and end-instrumentin the potential telehealth network must be defined. Also,the capabilities of the persons using the telehealth systemplay an important role in defining performance requirements.For example, the performance required of a telehealth linkconnecting physician specialists to a family practice phy-sician might be different than if that link were connectedto a nurse practitioner or emergency medical technician.The observation and processing capabilities of the peopleshould be considered in defining performance requirementsof a telehealth link.

Data Collection for Determining Requirements. The bestapproach for determining functional, structural, and per-formance requirements for a telehealth system is to collectdata concerning the needs of the current health system.These data should be based on actual activities within thecurrent system and may include a log kept by the healthcare providers concerning additional linkages or supportthat would have been useful.

Table 8 contains a fairly comprehensive set of data thatmight be collected by a health care system in order todetermine its requirements for telehealth support. Thedata indicated in the table range from simple identificationand stEmmaries of the types of cases and patients seen tologs of consultation support obtained or desired.

If the information listed in Table 8 is complete and repre-sentative, telehealth requirements can be developed whichaccurately reflect the realities of the specific health caresetting.

Stage II: Identification of System Constraints

The essence of c,is step is the recognition of inherenttations on a potential system. These might include legal,attitudinal, and economic constraints. The most obvious tyresof constraints are those that may be imposed externally. Forexample, a state - laws regarding the use of non-physicianproviders may preclude certain telehealth approaches forisolated rural clinics. A related constraint might be tele-health's effect on malpractice insurance premiums. However,information inquiries to four operating telehealth systemsby MITRE diu not reveal rate increases as a result of patientcare-related telehealth activities.

The attitudes of the community members and medical practi-tioners involved in a telehealth application could be apowerful constraint. Negative attitudes may -gradually70

able tiDetailed Site Data Collection

DATA ITEM SOURCE TELEHEALTiI DESIGNRELATIONSHIP

1. Number of acute patient visits(by type of problem/diagnosis)

a. Initialb. Follow-up Scheduled

Unscheouled

2. Number of other visits(by type of service provided)

3. Viss. distribution by day ofweek, hours

4. Number of referrals to otherphysicians or institutions(by type of physician or institu-tion); type of health problem(diagnosis); home location ofpatient

Number of telephone consul-tations by type of consultant,consultant location, healthproblem (diagnosis), and time ofday; number and type of consul-tations associated with referrals

6. Provider estimates of additionalinformation transfers/exchanges(e.g., views of lesions, x-rays, heatsounds) that would facilitate/improve consultations in item 5above; identify consultations asso-ciated with referrals

7. Provider estimates of informa-tion transfer capabilities(e.g_, views of lesions, Y

heart sounds) that woe: :j.referrals in item 4 above

8. Provider estimates of consulta-tions that would have beenattempted if specific informa-tion transfer capabilities (e.g.,views of lesions, x-rays, heartsounds) had existed. Identifyassociated patient visits bydiagnosis and time of day;provider locations and types;patient home locations

EF'

EF

EF

EFiMR"

SL

SL

SL

Potential frequ?ncy ofsystem use

Telehealth charge structure:potential system impact

Communications need; impacton information storage

Identification of applicabletechnology; location andfrequency of activity; addi-tional patient expense

Potential application of tech-nology; telecommunicationslink requirements; frequencydistribution of interactions

Technology applicability andimpact estimation

Technology applicability andimpact estimation

Technology applicability andpotential impact; telecommuni-cation requirements

'EF = Encounter Form"MR = Medical Record

""SL = Special Log

871

change, through education and experience, but the developmentof a telehealth approach may be severely impeded until suchbarriers are overcome.

Most telehealth approaches are constrained to some extent byeconomics. This would include limitations on capital invest-ment or operating funds. However, such co-)strai_zts may beabsolute or relative, as in the case of operating cost beingoffset by increased revenues or savings in other areas afterthe establishment of the telehealth system. This would bethe case if the introduction of telehealth Jinkages broughtnew patients to a rural clinic.

Third-party reimbursement policies concerning non-physicianproviders and teleconsultations are probably the most criticaleconomic/legal constraint on the telehealth field. The states'Medicaid policies vary,cput'generally they do not provide forreimbursement for services rendered by nurse practitionersand physician assistants, or for certain types of consulta-tions.* Although some of these limitations are likely tochange through legislative action in the near future, anyrelevant economic/legal constraints must be addressed carefullyin considering the desirability of a telehealth system._

Stage III: Definition of Telehealth System Alternatives.

The first two stages in the process of defining and evaluatingtelehealth alternatives identify needs that should be met bythe telehealth network and constraints on the manner in whichthese needs may be met. The third stage involves the defini-tion of alternative technology approaches to satisfying thehealth system's needs: This requires information provided inearlier Handbook sections concerning communications systemsand end-instruments, as well as the data collected in theprocess of determining telehealth system require-.Ants.

For example, alternatives might be developed involving broad-band and narrowband approaches for providing consultation/diagnostic support. FurtheI, within each of the functionalapplications (patient care, education, and administration),different levels of capability mi_ght be identified. Considera-tion could be given to a capability for (1) voice communicationonly, (2) voice plus data/telemetry, (3) voice plus data/telemetry plus video, or (4) voice plus darn /telemetry plusvideo plus body orifice viewing. The level chosen affectsthe type and degree of consultation/diagnostic assistancethat can be provided as well as system costs.

*Teleconsultations suc as remote EKG Interpretation are cur-rently reimburse

72

Non-telehealth alternatives also should be identified andincluded in all analyses of the relative advantages and dis-advantages of telehealth approaches. For example, the alter-native to telecommunication-based linkages between a ruralclinic and a remote source of specialist assistance might bethe provision of a mini-bus service to transport patients.Another alternative might be the periodic importation of suchspecialists for the operation of scheduled specialty clinics.Each of these alternatives has different operational charac-teristics, costs, and abilities to satisfy needs of a problemsituation. The purpose of the next stage in the process isthe comparison of such alternatives.

Stage IV: Comparison of System Alternatives

Once a set of alternative approaches has been assembled, thenext step is to compare the capabilities of these alternativesas a prelude to the selection of a specific solution. Thealternative systems should be compared along a number ofdimensions. The first dimension of comparison is that offunctional performance. The term "functional" is emphasizedto distinguish it from "technical" performance.

Functional Performance Capability. Functional performancerefers to the capability of a particular configuration tosatisfy the application needs of the system, whereas, techni-cal performance refers to such characteristics as resolution,gray-scale, and transmission rates. It is not necessarilythe absolute technical capability of the configuration thatis most important in comparing telehealth systems. Rather,it is the capability of the entire configuration and how itis used operationally to satisfy functional needs that sho..11.3be the primary factor in selection of a configuration.

Therefore, two telehe'th configurations may be compared whichutilize different video transmission systems, one of whichhas a higher resolution and gray-scale range than the other.However, if both of these video transmission systems providesufficient resolution and gray -sole range for the intendedneed (e.g., x-ray viewing, dermaL,--logy examinations, and EKGtransmission), their functional performance capabilities areequivalent with respect to the needs of the system. A greetertechnical performance capability of one of the systems wouldbe relevant to an extension of the system's use Into new appli-cation areas. Therefore, this factor should be taken intoconsideration under the heading of "flexibility" or "futureexpansion capability" of the configuration but it is notrelevant tr current functional requirements.

I_ similar situation exists in comparing the capability of twointeractive broadband television systems for continuing educa-tion purposes when one is a color system and the other is

73

black and white. One should examine whether the absence ofcolor restricts the types of educational programs that canbe conducted. This is the functional performance capabilitythat is important for comparing the two systems.

In comparing functional and technical performance capabilitiesof alternative configuratioT, the performance of the entireconfiguration that is being compared, not simply the capabili-ties of specific components within the configurations. Forinstance, suppose two configurations are compared whichutilize video transmission for the transmission of x-rays.A zoom lens may provide enough enhancement in effectivefunctional performance to make a lower resolution system aseffective as a more expensive system with higher resolution.This presumes that there is some level of visual quality ofthe transmitted image that is sufficient for the diagnosticpurpose, and that any increases in visual quality beyond thatlevel ark_ diagnostically unnecessary-even though they may beemotionally appealing.

The human component of the telehealth system can have a notableeffect in modifying t. functional performance capability ofthe system. For examp_Le, the use of medical or skilled nursingpersonnel to describe color characteristics of dermatologicconditions, or shading of microscope slides, may largely pre-clude the need for color transmission of certain types ofimages and thereby significantly reducing the cost of therequired video system. In fact, viewing the telehealth systemas a means of supporting and augmenting the verbal informationprovided by trained medical personnel may be the most realisticmanner of assessing the place of a telecommunications systemin the consultation /diagnostic process.

Since a telehealth system p '-oviH s for enriched informationflow between users, the time required to accomplish that.infor-mation flow may be significant. Therefore, the total timerequired by each alternative telehealth configuration to meetthe functional needs of the system must be considered. If twotelehealth configurations are being compared, one whichutilizes slow-scan television with an 8-second picture trans-mission time, and the other which utilizes a slow-scan Tele-vision system with a 78-second transmission time, this differ-ence must be noted and its significance considered as partof the determination of functional performance capability.Depending on the functional requirements, a lower qualitypicture may be sufficient if it can be delivered quickly.

An excellent example of this type of situation occurs in theteleconsultation services provided by Marine Medical Servicesto the tuna fleet on the West Coast.L9 Communication with74

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Capital investment costs include the costs of end-instrument--ouipment, communications equipment, and facility conscructionor modification. Initial assessment of the first two capitalinvestment categories can be obtained from material containedin this volume. The last category is dependent upon specificlocal conditions.

Since capital investment requirements preclude initiation ofthe project, consideration should he given to lease versuspurchase approaches to the acquisition of capital equipment,or to financing arrangements which might lower the initialoutlay. Where such arrangements are utilized, the amortiza-tion and debt payments associated with the purchase of thecapital equipment may be handled as part of the operatingcost comparisons.

Operating Costs. Costs generally include the categories oftransmission, equipment maintenance, personnel, facilities,and utilities. The last three categories are only indirectlyrelated to implementation of a telehealth system, and it isimportant to point out that in estimating operating costsassociated with the technology system, only the charges thatare directly attributable to the system should be -luded incost comparisons of alternative configurations.

Transmission costs are uniquely associated with telehealthinformation exchanges. These costs Include such items asthe telephone charges associated with the establishment of anarrowband telehealth network. Maintenance costs may beestimated as a percentage of the cost of capital equipment,when more specific information relative to the cost of amaintenance contract for a specific configuration is notavailable. Current technology, which involves largely solid-state techniques, should yield average annual maintenancecosts somewhat less than five percent of equipment cost. Thismay differ significantly if equipment is mobile or subjectedto severe environmental extremes.

In economic terms, the proper way to compare the costs ofalternatives would be to compare the present values of thefuture cost streams associated with each alternative. Thiswould take into account, in terms of current dollar values,the capital, operating, maintenance, and replacement costs ofthe equipment associated with the configurations. This per-mits comparison of configurations having different replacementcycles as well as different initial and recurring costs. Sucha detailed comparison probably is not warranted in the initialconsideration of a telehealth application, but it should beundertaken if major network investments are being considered.Such comparisons can also include tax aspects of the capitalinvestment and recurring costs.

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Comparison of the revenue _generating capability of alternativeconfigurations is the other major element in the financialdimension. First, different configurations may facilitatedifferent ranges and volumes of services and thereby generatedifferent total revenues. Second, although not considered asdirect income generation, different ranges of capabilities maypermit other costs within the system to be deferred. Forexample, in considering the alternatives of real-time inter-active television and slow-scan-video, differences inrevenue generating capability might exist. The more expensivereal-time interactive television could be used for a widerange of continuing medical education purposes in additionto its patient care uses. In contrast, the slow-scan systemwould h, Limited to individual fixed images r_uch like a remoteslide projector. Similarly, the real-time interactive systemmight attract other education) and training services not re-lated to the health function and these could be used togenerate income. However, the slow-scan television system

be able to reach a wider potential audience because itca- use the telephone distribution network rather than re-qu.l.ring a fixed microwave transmission system.

The same income generating aspects of these two configurationswould have different effects on cost deferral. The real-timeinteractive system, because of its greater range of applica--ions, may result in reductions in travel and non-productivetime. However, administrative applications of the same twotransmission systems for purposes of transmitting images ofdocuments would involve no cost savings differences, despitethe higher information rate involved in the real-time system.

When looking at the cost.deferral aspects of alternative con-figurations it is important not to credit higher capabilitysystems with reductions in costs that would not normally beincurred. For example, if the altt_rnatIlve to education pro-gramming over the real-time system would be no investment inth-t educational function at all, then costs ass_ciated withtravel to obtain the education are not really "cost savings".Cost savings can be credited to the telehealth configurationonly if the educational program would ha :,2 been undertaken inthe absence of the telehealth system.

Other Factors. A number of other capabilities should be con-sidered, although not to the same extent as the precedingones, in comparing alternative configurations. These includesuch factors as:

1. Flexibility of = application - What other functions can beperformed with a given configuration beyond those included inthe list of functional requirements?

77

2. Reliability - Are any of the configurations likely to besubject to problems of equipment reliability or tranmissionlink performance?

3. Developmental Risk - Is any ol the equipment in thealternative configurations likely to require developmentactivity before they can be installed?

4. Maintainability - Arehe subject to significantparts, or contracting forpersonnel?

any of the configurations likely tomaintenance problems, e.g., spareservices, or training of local

5. Training Requirements - Do any of the configurationsrepresent significantly more difficult requirements inoperating skills which might cause training needs or useracceptance to become significant problems?

6. Privacy - Do any of the configurations present significantrisks of violation of personal privacy?

7. Growth Potential Do any of the configurations offersignificantly more or less capability for future expansioninto other application areas?

The above factors can be reviewed initially by simple con-sideration of whether gross significant differences occur.At an early stage of comparison, only major distinctions inthese factors are worth concern cc.apared to differences inthe major dimensions discussed above.

Stage V: Selection of System Approach

Although previous discussions addressed various methods forcomparing features of telehealth alternatives, there is stilla need to select the "best" alternative approach. This some-what imprecise word, "approach", indicates, at this preliminarystage, that definitions of alternatives are somewhat unprecise.That is detailed design analyses, specification, and installa-tic-a cost estimates have not been made to the extent for de-tailed budgeting, ordering of equipment, and implementationplanning. Therefore, to speak about the selection of alterna-tive "approaches" is to remind the reader that small differencesbetween alternatives at this stage are likely to disappear whendetailed design and implementation stages are reached.

One of the alternative approaches to be consideredapproach that involves not using telehealth. EvenIt may have sc7rie attractive features and benefits,situations telehealth simply may be too expensive orsufficiently relevant to high-priority needs.

is thethoughin

78

somein-

However, a decision not tc use telehealth does not neces*arilymean doing nothing. Procedural and organizational changes inthe health care delivery system may provide significant benefitswhen they are appropriately used. The frequency of need, theimmediacy of consultation problems, the likelihood of patientsreturning to the local center to participate in specialtyclinics, the availability of specialists traveling to remotelocations, and similar alternatives should be reviewed in com-paring such approaches with telehealth. They must be con-sidered as part of the process of determining whether or notto proceed with telehealth.

Initial Questions. First, one must consider whether thecapital investment cost: associated with the various tele-health approaches are affordable. In other words, is thecost of implementing a telehealth approach for the particularlocal situation beyond reasonable expectations of availablecapital? If the answer is "yes," this is the time to recog-nize su,_ a situation and look for other ways of resolvinghealth care delivery problems.

Does telehealth offer the only feasible means of providingessential services? If the services are vital, ccr7e meansmust be found to provide them. And if telehealth is the onlyfeasible means of providing the services, then the problemecomes one of selecting among alternative telehealth approac! es

Most decision makers prObably will find themselves somewhere,etwe,-.!n these two extremes; that is, some telehealth approachesare affordable and the services to be provided, while notabsolutely essential, are highly desirable. Telehealth is)robably not the only feasible approach, but it is anattractive one.

:liminaring, for the time being, alternative approaches that'ail to satisfy basi- performance requirements, it is oftenaifficient to rank the alternatives for each of th-2 areas ofomparison (e.g., functional performance, cost, and flexibility).!cite often a single alternative is a "dominant" solution;hat is in most comparison areas it is as good as or betterhan other alternatives.

here several alternatives seem attractive but none is dominant,he relative importance of the areas of comparison should bessessed. For example are cost or performance capability ofuch greater importance than other characteristics? If one ofhe alternatives is clearly superior in one or both of thesereas, that alternative probably should be selected.

79

if clear-cut decis'_ons cannot be developed in rhis simplemanner, alternatives should be eliminated which clearlyless desirable than others until only two or three optionsremain. The remaining alternatives should then be subjectedto closer scrutiny with the aid of profess_onals who areskilled in system analysis and cost-effectiveness techniques.

Example of the Selection Process

A simple selection rrocesL. might occur in the following manner.A small group prac.ce in a rural community rt..quires special-ist consultation _ccvices to support their ambu.atory andhospitalized prtent-. Their principal needs art in the areasof radiology, cardiology, otolaryngology, and ophtalmology.The distance to the nearest community with specialists inthese areas is approximately 80 miles, and transportation issometimes complicated by severe weather conditions. Thecurrent approach of referring all patients requiring suchservice :s unsatisfactory.

A non-telehealth alternative would involve a combination ofseveral approaches referring patients whose treatment or con-sultation could not be deferred, scheduling periodic clinicsin the local community for patients whose :onditions permitsome delay, and obtaining delayed consultations, by means ofx-ray films and EKG records that are mailed to ap ropriateconsultants for review.

One telehealth alternative being considered is the use of aslow-scan television system for consultation and diagnosticsupport via the telephone network. This system would permittransmission of heart sounds, EKGs, and video informationsuch as x-rays and patient views. The alternative telehealthapproach being considered would also utilize transmission ofheart sounds and EKGs, but it would employ an interactive,closed-circuit television system using 3 specially constructedmicrowave radio system between an erban medical center andthe local group practice_

Selecting among these alternative approaches might proceed byjudging whether or not the non-telehealth approach would besufficiently responsi% to the time requirements of t'-'e localpractice, and whether it would result in the loss of localpatients whose needs are not met by the local system. Dataconcerning residents who avoid the local practice or whoresist referral to outside specialists, would help in makingthis judgement.

When the two telehealth approaches are compared. both arefound satisfactory with respect to functional performancec: ,ability. However, continuous frame (broadband) television

80

system provides a sense of "presence" between the communica-tors, by providing continuous 'full-motion video and trans-mitting changing facial expressions and other forms of "relylanguage". Tt has some additional capability for specialtyconsultations such as orthopedics and speech therapy thatmust show patient motion. Finally, slightly better resolu-tion can be achieved and th's results in shorter con=.ultationtimes than one-frame-at-a-time slow-scan television.

The capital investment requirement for the slow-scan systemis between '$40,000 and $50,000, since it utilizes the tele-phone system for transmission and requires no capital in-vestment in \a communications network. The broadband systemrequires an \expenditure of between $200,000 and $303,000,primarily to\accommodate the construction of a microwaveradio link between :he i:rban community and the local practice

Operating costs of the narrowband system, wh-i-h would includetelephone usage charges and a WATS system ;h. -rge, would berc hly equivalent to the operat'.ons and maintenance chargesfo the broadband communications system. Transmission ofvideo images in :he narrowband system would take approximately80 seconds, compared to instantaneous transmission of videoover the broadband system.

With respect to se-ondary level capabilities of the twoapproaches, the broadband system permits the transmissionof continuous video communication with t-ie local communityfor purposes of continuing education, administrative con-ferencing, and other health and social science services.The narrowband system would permit only single-frame videoinformation to be transmitted 4o the local community. Theareas of reliability, development risk maintainability,and training requirements are likely to be similar for bothapproaches.

Expansion of the narrowband system is simpler and less ex-pensive than expansion of the broadband system because nocommunicati,-ns system construction is required to initiatetelephone-based activity at additional sites. New locationscan participate in the activities of a narrowband telehealthsystem simply by the installation of end-instruments at eachnew site.

If the selection problem is addressed in terms of comparingthe two approaches only on the basis of whether they satisfythe immediate needs of t:ie rural group practice, then bothwould be considered acceptable. Both systems meet c-nsulta-tion needs in terms of minimum functional performance capa-bility, although the broadband system would probably be moresatisfying to the participants in an individual consultation.

81

They are ". quivalent" in the areas of operations and main-tenance costs. In term.- of capital investment cost, thenarrowband approach is considerably less expensive than thebroadband approach.

Considering secondary factors, the two approaches are approxi-mately equivalent in all areas except flexibility of applica-tion and growth potential. The broadband system has greaterflexibility of application, but the narrowband system issignificantly easier to expand.

In summary, both systems will perform the essential functionsadequately but they differ significantly with respect to cost.Some sacondary factors favor the narrowband system; othersecondary factors favor the broadband system. Therefore, ifa decision is to be made on the basis of major differences,the least costly alternative approach would be selected.Another line of reasoning would be to recognize the signifi--int cost differential between the two approaches and todetermine if the additional advantages of the broadbandsystem could be considered sufficient to make up the signi-ficant cost difference. Unless cost is no object or thereis a significant val_le placed on educational applications,the narrowbznd system is likely to be the preferred alterna-tive.

This extended example is intended to illustrate a simplifiedselection process that first determines whether or not anyparticular solution tends to dominate all others. Next, asolution is sought on she basis of a major advantage ineither functional performance or cost- And finally, based onspecific needs and values of the potential user, any majoradvantge is balanced against less significant differencesto determine whether they outweigh the major advantage.

If neither of these arguments yields an obvious answer, thealternatives are assumed to be relatively tha same in per-formance -Ind cost. In such cases, selections are going tobe made on the basis of secondary factors. In the absenceof characteristics that would tend to eliminate one alterna-tive or the other, such as significant maintenance or relia-bility problems, the selection usually should be made on thebasis of factors related to flexibility of operation andgrowth potential. The significance of these factors is in-fluenced by local characteristics and must be determined by*he judgement of the potential user. If an initial system:apability is part of a larger, expanding system, growthpotential might be given the most significant weight in theselection. If physicial expansion of the system is unlikely,then flexibility of application would be the more significantfactor.

82

Obviously the selection process is not likely to be eitherstraight-forward or tot ily quantitative. Where the charac-teristics of alternatiNcs do not dictate an obvious choice,the judgement of those who will be using and depending uponthe system should 1 the determining factor.

83

7 PAYING FOR TELEHEALTH

Regardless of how capital funds for a telehealth system areobtained, provision must be made to amortize system costs,allow for depreciation and replacement, underwrite opera-tional expenses, and pay for any other costs involved inusing the system, such as the fees of consulting specialists.

Three fundamental issues arise in the consideration of pay-ment alternatives:

.1. Who incurs the costs involved in implementing andoperating a telehealth system?

2. Who receives what types of benefits from the opera-tion of a telehealth system?

3. What payment/reimbursement mechanisms seem appro-priate and feasible?

Who Incurs Telehealth Costs?

At the present stage in the development of telehealth systems,the initial investment in ri telehealth capability is assumedto be made by health care providers, either individual or insome form of joint-venture agreement. The providers may beindividual practitioners, group practices, hospitals, nursinghomes, community groups, or other organizations that couldbenefit from participation in a telecommunications-basedhealth care network. Some funds currently are availablefrom the federal government through research and demonstra-tion grant programs investigating new approaches to healthcare delivery. Other federal and foundation sources may alsoexist, but such sources will be able to support only.a limitednumber of new initiatives.

Telehealth operating costs depend upon the type of systembeing used and they may be incurred in several ways. Broad-band telehealth systems are likely to involve significant

85

c4i-e 1'1 1 4-2.4

capital investment for communications links. Since theselinks are fixed, the operating costs are likely to be in-curred by the same individuals/groups who constructed thesystem.

In the case of narrowband telehealth systems that utilizethe telephone network, operating costs for communicationspurposes may be incurred either by individuals initiatingconsultation requests or on a shared network basis, usingWATS services. When telephone costs are incurred on a call-by-call basis, the person initiating the call generally willbe charged for the cost of the individual communication.In the case of rural health applications, long distancetelephone charges are levied on the one who initiates aconsultation or administrative call. When a number of siteshave jointly developed a narrowband telehealth network,WATS service may be utilized. This involves the sharing oftelecommunications costs among network users on a formulabasis. Educational application of telehealth may involvemore complex cost incurrence for telecommunications becauseconference call arrangements would have to be utilized inorder for all members of the network to be involv&I simul-taneously. In general, however, the call initiator wouldincur the direct charge from the telephone company.

Costs incurred by patients would be a direct function of thecharge structures established by health care providers Inorder to recoup the cost of establishing and operating thetelehealth network.

Who Receives Telehealth System Benefits?

Telehealth benefits can be appropriately considered in termsof three groups -- patients, providers, and the health system.

Patient Benefits. If telehealth fulfills the expectations ofits advocates and field experience is consistent with theresults of analytic studies, telehealth should provide anumber of important benefits to rural residents. If specialistcare can be made available at the primary care level, thenfewer patients should be referred to specialists. In turnthis should mean fewer delayed and avoided consultatiz.ns,which should result in 2ess severe illnesses and, logically,reduced hospitalization. The ability to treat more complexcases at the local level also would increase the - ontinuityof care provided to rural residents. An improved capabilitywithin local level health care systems shoula reduce theavoidance of assistance because of the expense and incon-venience involved. Most directly, the patient would not haveto travel to other communities for the resolution of healthcare problems; and incur associated expenses such as lost wagesand child care.86

Provider Benefits. The local primary care provider can bringimproved decision- making capability to bear on local health

-care problems through col:zultation with distant colleagues.This should reduce the sense--,f isolation and anxiety facedby many rural providers. In addition, prpvision for back-upas3istance is easier with a telehealth system, and the re-sulting opportunity for increased leisure and educationalactivities should enhance providers' satisfaction in ruralsettings.

Telehealth aJsc, may improve the financial basis of the ruralpractice. The ability to deal with a broader range of healthcare problems at the local level may reduce the loss ofpatients to distant communities as well as permit localfollow -up rather than continued interaction of local patientswith distant providers. Telehealth may permit a ruralphysician or group practice to increase their "cat2hment area"through the establishment of satellite facilities staffed bynon-physician providers. Also, the capability of telehealthsystems may satisfy the requirement for the direct supervisionof physician extender now required by state Medicaid systemsand/or licensing agencies. Finally, telehealth systems canprovide for increased provider education, through both theprocess of consultation and the delivery of continuing medi-cal education programs.

Secondary/tertiary care providers also may benefit from tele-health systems through an increased base of referrals andhign1:%r productivity because initial workups will be readilyavailable from primary care providers. Further, teleconsul-tation will tend to red'ice unnecessary referrals to secondary/tertiary levels. These factors, assuming availability ofreimbursement may also improve the financial status at thislevel of operation.

Health System Benefits. In the larger sense, the entirehealth care system may benefit from the proad and appropriateapplication of telehealth systems. If telehealth systemsare successful in permitting a wider range of cases to behandles1 at local levels, a general reduction should resultin the cost per episode of illness. Should the benefits tc,local health care providers prove to be obtainable, signiE-Icant improvements may result in the ability to attract andretain providers for rural areas.

What Are Appropriate Telehealth Payment/ReimbursementMechanisms?

The technical feasibility of telehealth has been demonstratedI n_a_var ty o f _set ings arLd- aaap1icat-1 .ons- lk,weve r, -such -sys t ems will have little impact on the provision of ruralhealth care if appropriate and reasonable payment/reimburse-

37

ment mechanisms do not accompany the effective applicationof technology. Benefits can accrue only if telehealth sys-tems are utilized, and utilization on a sufficiently broadbasis will occur only if theme are appropriate payment/reimbursement mechanisms.

The first and most critical question is whether or not reim-bursement will be available from third parties for servicesprovided using telehealth systems. Certain telehealth serv-ices are already being reimbursed and others have beenindicated as "reimbursable" under current approaches anddefinitions. Remote reading of EKGs is regularly reimbursedunder current third party systems and remote reading of x-rayshas been characterized as "probably reimbursable". There isless willingness on the part of third party payors to reimbursefor consultation services based on visual images of patients.

A lack of consistency exists in reimbursement policies be-cause of the basic fragmentation of our nation's health caresystem. On the basis of limited evidence, it appears thatthe absence of reimbursement for telehealth services doesnot result primarily from the medical adequacy of the serviceprovided, but from uncertainty as to the effect of tele-consultation reimbursement on the utilization of health careservices.

Third party payors are concerned about the effect that tele-consultation might have on the utilization of referral ser-vices. Dismissing the possibility of excessive use of tele-consultation if reimbursement is widespread, short-term in-creases in total health care costs may occur before thepotential longer -term benefits of such services are recog-nized.

Several effects on health care utilization are possible asa result of teleheal::;, r .t..Torks. Increases might occur inthe incidence of con_ Ilt -7-on among primary, secondary andtertiary providers due to the capabilities provided by thetelehealth system and to the availability of reimbursementfor the provision of such services. Studies and surveysreferenced above have indicated that the need for patientreferrals to secondary and tertiary care levels would bereduced because telehealth linkages could be substitutedfor a substantial proportion of pre-telehealth referrals.However, there is uncertainty concerning whether the presenceof telehealth systems might not also result in additionalreferrals that previously should have been, but were not,made.

88

At present, adequate information is not available regardingthe effect of telehealth systems on utilization of health careservices. The Health Underserved Rural Areas Program is spon-soring telehealth research that should provide significant in-formation in the critical areas of utilization and reimbursement.

Assuming the availability of reimbursement, on either a regularor experimental basis, payment mechanisms and charge structuresstill must be develol,ed. It seems reasonable to expect con-sultants to be reimbursed for telehealth consultations in thesame manner as they would be reimbursed for physical consulta-tion with patl.?nLs. Charges would have to be established forteleconsultatfon :.ctivities that do not result in an immediatereferral. Telec_pnc-ltations resulting in immediate referralsshould probably be absorbed or included in the fee for areferral visit.

The remaining question is how the costs of the telehealth sys-tem should be recovered by the primary care provider. Thereappear to be basic approaches. First, the primary care pro-vider charges patient when the system is used in his behalf.This approact- l_cf treat the telehealth system in ::he samefashion as a c ostic or therapeutic device °_-.uch as x-ray ordiathermy equipmcnt.

The second approach would view the telehealth system as ageneral resource of the practice, similar to the telephone,sterilization equipment, or the blood-pressure cuff. Thecost of the system would therefore be a part of the practiceoverhead.

The first approach levies charges on a patient from whom thesystem is used. The second approach includes a small chargein eac,1 patient's bill, spreading the cost of the telehealthsystem across the entire patient population. Both approacheshave advantages and disadvantages.

Establishing a charge for the use of the telehealth system hasthe obvious merit that its use for a specific patient canreadily be identified, just as it can be for the use of diag-nostic or therapeutic instrumentation. Less obvious is howsuch a charge should be established and what effect it mighthave on the introduction and utilization of a potentiallyimportant innovation in health care delivery. Without someknowledge of the probable utilization rate for such equipment,it would be difficult to establish a reasonable charge on aper use basis.

89

Should a flat charge be levied on the basis of the occurrenceof a teleconsultation, or should it be based on elapsed timeor the number of transmitted images involved in the consulta-tion? Will establishing a per-patient charge for the use ofthe telehealth system inhibit its use and thus impede itsacceptance and the devel -?.nt of creative applications?If the telehealth system ; to be employed for administrativeand/or educational purposes, what proportion of total costsof the telehealth system should be allocated to these functionsand what proportion to patient-related consultation activity?These questions indicate the likelihood of somewhat arbitrarycharge structures until additional experience has been gainedwith the utilization of telehealti- s

A telehealth system does not create new information or moreprecise information. Rather, it provide:: the capability toexchange information more efficiently and more broadly sothat improved decision-making capability can be brought tobear for the benefit et the patient.

The telehealth system is very much like the telephone. Itpermits the exchange of information between providers ofcare for the benefit of the patient. Even though we couldidentify the fact that a particular telephone call was madein relation to a particular case, we do not attempt to chargepatients for the use of the telephone. Instead, we includeit as an overhead item in the provision of care. At theprfsent stage of development of telehealth systems, ratherthan risking inappropriate charge structures and the con-comitant possibility of impeding the growth of knowledgeand skill in the utilization of telehealth, an approachsimilar to the one for telephone is recommended to covertelehealth costs. This issue may, and certainly should, bereconsidered in the future. However, considerably moreexperience should be obtained before attempting to developa charge structure on the basis of individual patient use.

Field experience with operational telehealth systems willincrease significantly in the near future, particularlyexperience with systems that utilize the telephone networkfor transmission. This handbook presents the current levelof understanding of the critical elements and issues. It isa guide for proceeding into the future but it is not a defin-itive set of answers. Hopefully the promise of telehealthsystems can be achieved through intelligent and appropriateapplications, and that this volume will be useful in achievingthat goal.

90

APPENDIXTELEHEALTH PROJECT SUMMARIES

91

1 o :

ALABAMA, ANNISTON

TITLE: East Alabama Rural Health Foundation

PERIOD: 1976-1979*

TECHNOLOGY: Computer, Telemetry

APPLICA:IION: rimary Care, Administration

The East Alabama Rural Health Development program wasinitiated to help 111-,viate the severe shortage of healthcare providers in a number of counties in Eastern Alabamathrough the establishment of nurse-practitioner staffed-clinics. These clinics are currently in developmentalstages. The program proposes the eventual developmentof a computerized medical records and billing system tolink the nurse practitioner-staffed clinics with eachphysician's office and a group physician practice.Currently, software is being developed and computerequipment has been installed in the group physicianpractice.

REFERENCE:

CONTACT:

Anderson, C.. lnd W. Rappaport, TechnologyApplications in Rural Health Care Systexs.?`QTR -7537 (The Mitre Corpor-at ion: McLean,Virginia, Mav 1977).(2/)

Bill D. stout, m.n.P.O. Box 21271010 Christine AvemieAnn4_ston, Alabama

*Future date indicates end of funding nericd.

92

ALABAMA, BIRMINGHAM

TITLE: MIST--Medical Information Services via Telephone

PERIOD: 1969-Present

TECHNOLOGY: TelephoneWATS, Centrex Tie Line

APPLICATION: Primary Care, Education

MIST is a t:elepilone extension service of the University ofAlabama Medical Center at Birmingham which brings the Center'sresources to physicians and other health professionals state-wide. While used by many health professionals, MIST is aimedat assisting physicians in their day-to-day care of patients.Many of the questions phoned in by physicians pertain to tech-niques, procedures, equipment, or services. In 1971, DATL(Dial Access Tape Library) was added for physicians and nurses.DATL is widely used by nurses fo,-- teaching conferences.

REFERENCE:

CONTACT:

Klapper, M. S, and I. B. Harper, "MIST-- Obser-vations and Trends." Journal of the MedicalAssociation of the State of Alabama (April 1975).(13)

Margaret S. Klapper, M.D.Director of MISTRoom 111, Mortimer Jordan HallUniversity StationBirmingham, Alabama 35294

93

ALABAMA, BIRM1NGEAM

TITLE: 0I-Line Medicaid Billing Syster,

PERIOD: 1971-1973

TECHNOLOGY: Tele7hone Equipped with Care-r)ialers,Answer-Back Equipment, Computer

APPLICATION: Admfnistration

The intent of this project was to provide an on-line state-wide billing system for physicians' services. The systemdesign provided for point-of-service ;:er-inals on-line toa central computer to reduce the costs of submittingclaims from physicians' offices and prep al-ins, data forthe carrier. Data were entered from the physicians'offices on standard Touch ToneR telephones eouipped withcard-dialers. Patient information andconfirmation data were received from the central computerfacility via voice answer-back.

REFERENCES:

CONTACT:

94

Mesel, E., and D. D. Wirtschafter, "automationof a Patient Medical Profile from InsuranceClaims Data: A Possible First Step in Auto-mating Ambulatory Medical Records on a NationalScale." Health and Society. 29-45 (Winter1976)-(38)

Mesel, E., and D_ D. Wirtschafter, "EconomicAnalysis of an Automated Billing System forPhysicians' Services." Medical Care. 14:1037-1051 (1976)-(39)

David D. Wirtschafter, M.D.Director of Clinical Inforrf.Prion SystemsUniversity o.,7 Alabama809 S. 19th StreetBirmingham, Alabama 35294

1"

ALABAMA, TUSKEGEE

TITLE: Tuskegee Telemedicinc System

PERIOD: I973-Present

TECHNOLOGY: Telepho.te, 2-Way Audio/Data

APPLICATION: Primary Care

The Tuskegee Telemedicine System provides health care servicest..) a three-county area in southeastern Alabama. A total ofseventeen community sites will be serviced by two mobilevans, each staffed by a three-member team including a nursepractitioner, a laboratory technician/driver, and a nutri-tionist who work with a community-based coordinator. Eachvan is equipped to transmit EKG tracings via telephone tothe main clinic location to be read by a computer. Theinterpretations are then sent back to the mobile health unit.Additional equipment includes a facsimile for hard copytransmisFion and a telewriter that enables the Base HealthCenter physician t. write remote pr _scriptions for on sitefield use.

CONTACT: Cornelius L. Hopper, M.D.The John A. Andrew Clinir-sTuskegee InstituteTuskegee, Alabama 36088

95

ALASKA, ANCHORAGE

TITLE: ATS-6 Satellite Advanced Health Care andEducation--Alaska Health Exneriment

PERIOD: 1974-1975

TECHNOLOGY: Satellite, 2-Way Black-and-Mlite Telev:sion

APPLICATION: Primary Care

This project was designed to assess the potential of asatellite system for the presentation of health, education,and information programs. All four sites included inthe project had local exchanges in addition to ATS-1satellite radios which linked them to Tanana hospital,Anchorage Medical Center, an .7.thr ATS-1 sites. Ser-Acesincluded teleconsultation, the transmission of x-raysby the video capability, and EKG tracings over the audiocllannel. The demonstration also included the computerizedpatient record system, Health Information System (HIS),developed by the Indian Health Service.

REFERENCES:

CONTACT:

96

Boor, J. L., G. Braunstein, and J. M. Janky,"ATS-6: Technical Aspects of the Health/Education Telecommunications ENperiment."IEEE Transactions on Aerospace and ElectronicSystems. AES-11, 6, 1015-1(1'32 (November 1975). (20)

Wilson, M. R., M.n., ancl C.Brady, "Health Care in Alaska via Satellite."AIAA Conference on Communication Satellites forHealth/Education Applications (Denver, Colorado,July 21-23, 1975)."°i

Martha R. Wilson, M.D.Office of Program DevelopmentAlaska Area Native Health ServiceAlaska Native Medical Center.Anchorage, Alaska 99501

ALAS"7A ANCHORAGE

TITLF Continuing Medical Education by Satellite

PERIM): 1977-1978

TECHNOLOGY: Satellite, Color Television

APPLICATION: Education

This project is a collaborative effort of the Indian HealthService, the Veterans Administration, and the Public ServiceSatellite Consortium. Live continuing medical educationbroadcasts are being received at the Alaska Native MedicalCenter weekly from the VET-SAT network over CTS satelliteby way of an interconnect at the Denver Up-link to the ATS-6satellite.

CONTACT: Mr. Robert B. ShamaskinDeputy PirectorLearnir7 Resources Stvice (142 A)Department of Medicine and SurgeryVeterans Administration810 Vermont Avenue, N.W.Washington, D. C. 20420

Martha R. Wilson, M.D.Office of Program DevelopmentAlaska Area Native Health ServiceBox 7-741Anchorage, Alaska 99501

John P. Witherspoon, PresidentPublic Services Satellite Consortium2480 West Sixth AvenueDenver, Colorado 80211

ALASKA, ANCHORAGE

TITLE: Operational Satellite Communication forHealth Care

PERIOD: On-Going

TECHNOLOGY:- Commercial Satellite, 2-Way Audio

APPLICATION: Primary Care

This project is a collaborative effort between the IndianHealth Service, The State of Alaska's Office of Telecommuni-cation, and Radio Corporation of. America (RCA). It is theoperational follow-on of the ATS-1 Satellite Doctor Call,the experimental program limited to the Tanana ServiceUnit. At the present time approximately 60 of the totalplanned 120 remote Alaskan villages are equipped with smallearth terminals and are conducting Doctor Call by satelliteon a 24-hour availability basis.

CONTACT:

98

Martha R. Wilson, M.D.Office of Program DevelopmentAlaska Area Native Health ServiceAtil,Aska Native Medical CenterAnchorage, Alaska 99501

ALASKA, JUNEAU

TITLE: ATS -1 Satellite- Doctor Call

PERIOD: 1971-Present

TECHNOLOGY: High-Frequency Radio, ATS-Satellite Radio

APPLICATION: Primary Care, Education

This demonstration project was conducted to gain experiencein the exchange of medical and educational information be-tween remote and urban Alaskan commun'ties via satellite.Emphasis was placed on the exchange of medical and healthinformation between health aides in twenty-six isolatedcommunities and Public Health Service physicians.

REFERENCE: Kreimer, 0., H. Hudson, and D. Foote,Health Care and Satellite Radio Communicationin Village Alaska. (California Institute forCommunication Research, Stanford University:Palo Alto, California, June /974). (41)

CONTACT: Martha R. Wilsc%,Office of Program DevelopmentAlaska Area Native Health ServiceAlaska Native Medical CenterAnchorage, Alaska 99501

1 Oj99

APPALACHIA

TITLE:a.

Veterans Administration ATS-6 Health. CareExperiment in App19c-hia

PERIOD: 19 74 -19 75

TECHNOLOGY: Communications Satellites

APPLICATION: Primary Care, Education

This project involved ten Veterans Administration hospitalsin the Appalachian region of the United States. It testedhow communications satellites can be employed on a cost-effective basis for biomedical purposes in terms of diagnosis,therapy and continuing Education. These experiments involvedweekl), telecasts with audio return over a period of elevenmonths in 1974 and 1975 and included video seminars, grandrounds, outpatient clinic activities, teleconsultatlons,and computer-assisted instruction.

REFERENCE:

CONTACT:

100

Annual Report: Exchange of Medical InformationProgram, Fiscal Year 1976. (Veterans Admin-istration, Department of Medicine and Surgery,Learning Resources Service: Washington, D.C.,August 1976) .(42)

Mr. Robert B. ShamaskinDeputy DirectorLearning Resources Service (142 A)Department of Medicine and SurgeryVeterans Administration810 Vermont Avenue, N.W-Washir_gzon, D.C. 20420

ARIZONA, SELLS

TITLE: Space Technology Applied to Rural PapagoAdvanced Oealth Care (STARPAHC)

PERIOD: 1975-Present

TECHNOLOGY: Microwave, 2-Way Audio/Video/Data, Slow-scan Video

APPLICATION: Primary Care

STARPAW: is a ground-based remote area heal `h care deliverysystem. It was designed to demonstrate the feasibility andpotential of utilizing space technology in communications andsystems engineering to upgrade health care access and delivery.The test site is southern Arizona's Papago Indian Reservation.This telemedicine system uses micrcwave transmission to provideinteractive color and black and white television, audio,and data communications between a central hospital-basedmedical facility at Sells, Arizona, and para-medical personnelattending patients in a fixed clinic (the Santa Rosa area)and a mobile clinic at a series of prescheduled remote siteson the reservation. It also provides referral and consulta-tion capability to the large Indian Medical Center in Phoenixthrough good resolution, slow-scan color and black and whitetelevision, that is transmitted over commercial dial-uptelephone lines. Thus the physician's skill, knowledge, andcapabilities are made available over great distances to patientsin remote geographical areas through the physician's assistantutilizing thr telemedicine system.

REFERENCE:

;ONTACT:

STARPAHC Systems Report, 2 Vols. (NationalAeronautics and Space Administration,Johnson Space Center: Houston, Texas, Con-tract .723)NAS9-13170, LMSC D566133, October1977).

Norman Belasco, SD2National Aeronautics and Space AdministrationLyndcn B. Johnson Space Center.NASA Road 1Houstoa, Texas 77058

101

ARIZONA, TUCSON

TITLE: Arizona Rural Health Federation

PERIOD: 1977-1979

TECHNOLOGY: Computer Terminals, Facsimile

APPLICATION: Primary Care, ,:ziministration, Education

The goal of this project is to organize a network ofcomprehensive health care services in a five-county areaof southern Arizona. Ther are now seven rural communityhealth clinics linked together in a communications network_When the project began in 1976 as the Southern ArizonaRural Health Initiative at the University of Arizona,plans included implementation of the Health InformationSystem (HIS), installation of a computer terminal at onelocation to establish close ties with a tertiary carecenter in Tucson, the utilization of direct telephone linesto link communities with the next higher level of healthcare, and use of facsimile for transmission of medicalrecords. New plans include using CB radios to link amobile health clinic: to a base community health center orhospital. Neither computer terminals nor facsimile wereproductive and have been discontinued. Services tobe provided within this system include primary care,health education programs, technical assistance, organi-zational development, and administrative support. Tele-phone is the major link for the present network.

REFERENCE:

CONTACT:

102

Anderson, C., and W. Rappaport, TechnologyApplications in Rural Health Care Systems.MTR -7537 (The Mitre Corporation: McLean,Virginia, May 1977).27)

Seth LinthicumExecutive DirectorArizona Rural Health Federation5447 East Fifth Street, Suite 227Tucson, Arizona 85711

CALIFORNIA, SAN DIEGO

TITLE: Navy Remote Medical Diagnoses System (RMDS)

PERIOD: 1972- Present

TECHNOLOGY: Slow-scan Television, Telemetry

APPLICATION: Primary Care

RMDS is an interactive slow-scan television system for linkingship-to-ship, ship-to-shore, and land-to-land points to providea variety of diagnostic services. Patient x-rays from navalvessels at sea have been examined via UHF, HI' and satelliteusing narrowband slow-scan transmissions. EKG and electronicstethoscope devices have been used to send physiologicaldata using UHF and HF links.*

REFERENCE: Rasmussen. W. T., and J. Silva, Navy RemoteMedical Diagnosis System. (Naval ElectronicsLaboraMy Center: San Diego, California,1976) -

CONTACT:

Rasmussen, W. T., R. L. Crepeau, and F. H.Gerber, Resolution Requirements for Slow-Scan Television Transmission of X-Rays. TR-150(Naval Ocean Systems Center: San Diego,California, 1977).(44)

T71111s T. Rasmussen, Ph.D.Naval Ocean Systems CenterBiomedical Engineering Branch, Code 8233San Diego, California 92152.

*Earlier versions of the system haVe operated between centralfacilities (San Diego and Port Huencme) and remote facilities(El Centro, San Clemente Island, and San Nicolas Island).

103

CALIFORNIA, SAN DIEGO

TITLE: TELEMED System in North County Health Project

PERIOD: 1977-Present

TECHNOLOGY: Telephone, 1-Way Slow -Scan Video

APPLICATION: Primary Care

The TELMED System in the rural-back country area of NorthSan Diego County is being developed and used to extendthe primary care coverage of the nurse practitioner andphysicians to provide 24-hour, 7-day a week communicationto the primary care clinic in Ramona. The systems havebeen placed in Santa Ysabel and Ranchito where qualifiedindividuals in the community are being traf_ned to act ascommunicators. The objective of the use of telecommuni-cations in these areas is to resolve the challenges ofthe small (100-2,000 population) rural community indeveloping a health care system.

CONTACT:

304

Dorothy RenoDirector, North County Health Services309 Firebird LaneSan Marcos, California 92069

COLORADO, DENVER

TITLE: 14ountain/Plains Outreach Program

PERIOD: 1976-1979

TECHNOLOGY: Computer, WATS

APPLICATION: Primary Care, Administration

This program is designed to provide improved health care torural areas of Colorado through the establishment of tele-communications and data processing linkages between healthresources of urban areas and newly formed physician-staffedprimary care centers in rural areas. The program includes acomputer data system with CRTs to provide on-line patientinformation. Planned uses for this information system in-clude evaluation of preventive health care methods, pharmaco-logic surveillance, health education, medical practice audit,and cost of care.

REFERENCE: Anderson, C., and W. Rappaport, TechnologyApplications in Rural Health Care Systems.MTR77537 (The Mitre CorporP-'on: McLean,Virginia, May 1977).(27)

CONTACT: Perry WarrenProgram DirectorMountain/Plains Outreach Program4545 E. 9th Avenue, Room 435Denver, Colorado 80220

105

COLORADO, DENVER AND BOULDER

TITLE: University of Colorado Seminars

PERIOD: 1973-Present

TECHNOLOGY: Microwave, 2-Way Audio/Video

APPLICATION: Education

The purpose of this project is to broadcast medical seminars,including grand rounds and clinical presentations, betweenthe Denver Medical Center campus of the University of Colo-rado and the campus at Boulder. Selected presentationsare also rebroadcast by Instructional Television FixedService (ITFS) to Boulder Valley Community Hospital.

REFERENCE:

CONTACT:

106

Chan, S., and J. R. Messick, 33 Telecommunica-tions Projects in Medical Education and HealthCare. (Office of Medical Education, Researchand Development, Michigan State Univ,Egi.ty:East Lansing, Michigan, March 1975).`

Norman FringerDirector of Biomedical CommunicationUniversity of Colorado - Medical Center4200 East Ninth Avenue, Hosp. Box A066Denver, Colorado 80262

6

CONNECTICUT, FARMINGTON

TITLE: Network for Medical Communications

PERIOD: 1971-Present

TECHNOLOGY: Microwave, 2-Way Audio/Video

APPLICATION: Primary Care, Education

This system uses live television to link the University ofConnecticut Health Center in Farmington with NewingtonVeterans Hospital and New Britain General Hospital. Usesinclude consultations, student education, and continuingeducation.

REFERENCE:

CONTACT:

Chan, S., and J. R. Messick, 33 Telecommunica-tions Projects in Medical Education and HealthCare. (Office of Medical Education, Researchand Development, Michigan State University:East Lansing, Michigan, March 1975).(45)

Sanborn, D. E., et al., "Interactive Televisionand the Rural Family Physician." Journal of theMaine Medical Association, Vol. 66, 276-279(October 1975).(46)

Warren Kypr-leManager, Interactive TelevisionThe University of Connecticut Health CenterFarmington, Connecticut 06032

1 1107

FLORIDA, MIAMI (DADE COUNTY)

TITLE:

PERTOD:

Telemedicine Hea10.- are Delivery in DadeCounty Florida Pena- Institutions

1974-1977

TECHNOLOGY Microwave Slow-scan, 2-Way Audio/Video,Facsimile, Audio Support Devices

APPLICATION: Primary Care

This system links Jackson Memorial Hospital with three DadeCounty penal institutions. Evaluation tasks includedanalyzing the effects of a telemedicine system on anexisting health care delivey system and studyil_g patientgroups randomly assigned to baseline and telemedicinegroups to evaluate the existing and upgraded systems.

REFERENCE: Final Report: An Evaluation of the Impact ofCommunications Technology and Improved Medical

CONTACT:

108

Protocol on Health Care Delivery in PenalInstitutions. (University of Miami MedicalSchool: Miami, Florida, NSF GrantNo. GI-39471,December 1976).(47)

Jay H. Sanders, M.D.Principal InvestigatorChief of MedicineJackson Memorial HospitalMiami, Florida 33157

GEORGIA, ATLANTA

TITLE: Georgia Regional Medical Television Network

PERIOD: 1967-Present

TECHNOLOGY: Two-Channel ITFS (Instructional TelevisionFixed Service)

APPLICATION: Education

This system services approximately thirty-one medical insti-tutions, primarily to provide continuing education for theparticipating health professionals. Run by Emory -University,the system operates out of Grady Hospital, the teachinghospital for the University. Between three and ten hoursper week are dedicated to broadcasting live medical programsin color by ITFS transmitter, including regularly scheduledmedical conferences, OB/GYN conferences, and cardiologyconferences. These programs are also rebroadcast for thebenefit of those who may have missed the live presentations.

REFERENCE:

CONTACT:

Kaminsky, A., "A Circulating Medical Libraryon Video Cassettes." Educational and Indus-trial Television. 9,3,41-44 (March 1977) .

(48)

Alan KaminskyBusiness ManagerGeorgia Regional Medical Television Network69 Butler StreetAtlanta, Georgia 30329

109

HAWAII, HONOLULU (AND PACIFIC)

TITLE:

PERIOD:

ATS-1 PEACESAT (Pacific Education andCommunication Experiment by Satellite)

1971-Present

TECHNOLOGY: Satellite, 2-Way Audio, Facsimile

APPLICATION: Primary Care, Education

PEACESAT is an interactive narrowband system servicingeleven nations or jurisdictions in the Pacific area toprovide health education and community services. Usesof the system have included teleconsultations betweenphysicians, teacher education, student classes, and sharingof library resources.

REFERENCE:

CONTACT:

110

Bystrom, J. W., "The Application of Satellitesto International Interactive Service SupportCommunication," Proceedings of the RoyalSociety of London, A.345,493-510 (October 1975)-(4

John W. Bystrom, Ph.D.DirectorPEACESAT ProjectUniversity of HawaiiHonolulu, Hawaii 96822

12 )

ILLINOIS, CHICAGO

rITLE: Bethany/Garfield Community Health Care Network

?ERIOD: 1972-1976

EICHNOLOGY: abMicrowave, Picturephone, 2-Way Audio/Video/Data

LPPLICATION: Primary Care, Administration, Education

'he goal of this program was to serve the Bethany/GarfieldIospital complex, including two community hospitals, three:tore-front health centers, and three drug -.-ellabilitationainics. The ov11 objective was to explo: e the use ofooth Picturephond1 and broadband television for solvingcommunications problems of a large health cE-e network in anrban ghetto area. Uses included in-service sraff training,ontinuing education of health officials, and L.upervisionf employees.

EFERENCE: Two-Way Visual Communications Expel-iment:The Final Report. (METCOR IncorpcETEOFTChicago, Illinois, December 1973)-(510)

ONTACT: Vernon ShowalterBethany Brethren.Hospital3420 W. Van Buren StreetChicago, Illinois 60624

10111

ILLINOIS, CHICAGO

TITLE: Cook Countyjkspit-tl, Department of Urology,Picturephon4Z)Network

PERIOD: 1972-1975

TECHNOLOGY: Picturephon4D, 2-Way Audio/Video

APPLICATION: Primary Care, Administration

Ten PicturephonejDwere located within the Cook CountyHospital multi-building medical complex. The basic objec-tive of this network was to improve administrative controland effective communication between the personnel and thepatients, and among the personnel themselves throughincreased and better visual and verbal exchange, and togenerally improve patient care.

REFERENCE: Chan, S., and J. R. Messick, 33 Telecommunica-tions Projects in Medical Education and HealthCare. (Office of Medical Education, Researchand Development, Michigan State University:East Lansing, Michigan, March 1975).(45)

CONTACT:

112

Irving M. Bush, .."-D.Division of 1: -' AyCook County1825 W. Harris.- StreetChicago, Illinois 60612

ILLINOIS, CHICAGO

TITLE: Illinois State Psychiatric Institute PicturephoneProgram

PERIOD: 1973-1974

TECHNOLOGY: Picturephone, 2-Way Audio/Video

APPLICATION: Primary Care, Education

This network was established to link the staffs of institutionswithin the Illinois Mental Health Institute Network, includingtwo mental health centers, a school for emotionally disturbedchildren, and three psychiatric institutes. The objectivewas to explore the utility of two-way visual communicationsbetween clinic "paramedirtal personnel and the consultativeexpertise at the hospital in solving mental health caredelivery problems. Use of the equipment facilitated contin-uous patient treatment, staff consultation and training,and communication flow regarding patient treatments and staffefforts.

REFERENCE:

CONTACT:

Chan, S, and J. R. Messick, 33 Telecommunica-tions Projects in Medical Education and HealthCare. (Office of Medical Education, Researchand Development, Michigan State University:East Lansing, Michigan, March- 1975).(45)

William H. LewisCoordinator, Administrative ServicesIllinois State Psychiatric Institute1601 W. Taylor StreetChicago, Illinois 60612

3

113

INDIANA, INDIANAPOLIS

TITLE: Medical Educat'onal Resources Program (MERP)

PERIOD: 1967-Present

TECHNOLOGY: Microwave, Cable, 1-Way and 2-Way Video,2-Way Audio via 1 lephone Talkback Device

APPLICATION: Education

This program seeks to enhance medical education within theState of Indiana. It is utilized mainly for continuingeducation, but has also been used on occasion in thetraining of medical students. Seven Indiana Universitycenters and over forty hospitals are serviced by thissystem. Additionally, one hundred locations participateIn a video cassette mailing program.

REFERENCE: Friman, E., "Medical Minicam Projection:Why Portable Color Systems Prove a Boon toMedical Uses of Television." Educationaland Industrial Television, 7,12,17-20(December 1975).k51)

CONTACT:

114

Friman, E., "The New Age of Medical Tele-vision Network..: The Potential Satellite'_:ransmission Holds for Networking MedicalEducation." Educational and TndustrialTelevision, 19-22 (May 1977).o2

ElTner FrimanDirectorMedical Educational Resources ProgramIndiana University School of Medicil_e110 West Michigan StreetIndianapolis, Indiana 46202

KENTUCKY, MOREHEAD

TITLE: Gateway Dilrict Health DepartmEnt

PERIOD: 1975-Present

TECHNOLOGY: Mobile Van, Telephone

APPLICATION: Primary Care, Administration

This newly formed districz health department provides publichealth services for the population et five northeast Kentuckyrural counties. A central district office is staffed by personnelwho rotate through the district offices located in each of thefive counties. A mobile van staffed by a dentist, hygienist andclerk travels throughout Morgan County remaining two or threemonths at each site. The GDHD operates three dental operatorieswithin elementary schools. A major objective of the GDHDs programis to provide existing administrative support services. A radiocommunications system linking support personnel in the field withthe core staff and a unified financial management system withformalized_linkages between third party payers and the districtoffice are being developed. The GDHD has entered into majorinnovative services delivery supported by The Kentucky MedicalAssistant Program (Title XIX Agency).

REFERENCE:

X)NTACT:

Anderson, C., and W. Rappaport, TechnologyApplications in Rural Health Care Systems.MTR-7537 The Mitre Corporation: McLean, Virginia,May 1977).(27)

Robert G. Matthews Jr., Ph.D.Gateway District Health DepartmentBox 666Owingsville, Kentucky 40360

115

LOUISIANA, BATON ROUGE

TITLE: Louisiana Health Television Network (LHTN)

PERIOD: 1967-Present

TECHNOLOGY: Cable, Microwave, 2-Way Audio Statewide,2-Way Video

APPLICATION: Education

The system is a statewide, closed-circuit medical televisionnetwork serving Louisiana's charity hospitals in nine cities.Also included in system are the Louisiana State UniversitySchools of Medicine in Shreveport and in New Orleans and theTulane University Medical Center in New Orleans. Networkcontrol is in Baton Rouge and is operated by the LouisianaEducational Television Authority on behalf of the State'sHealth and Human Resources Administration. Primarily aneducational project, LHTN seeks to provide programs to traininterns and residents, in-service education for nurses andparamedical personnel, and continuing education for healthprofessionals. Programming includes live conferencing withinstruction and taped continuing education prograr.s. Theservice of LHTN is supplemented by a videocassette subscriptionservice provided by the Louisiana State University School ofMedicine in New Orleans.

REFERENCES: Chan, S., and J. R. Messick, 33 Telecommunica-tions Projects in Medical Education and Health

CONTACT:

116

Care. (Office of Medicel Education, Researchand Development, Michigan State University:East Lansing, Michigan, March 1975).45)

Stephens, H. J., "'Doctor to Doctor' Via CCTV:Continuing Medical Education in Louisiana."Educational and Industrial Television (July 1970.T53)

Harold J._Stephens, Jr.Acting DirectorBiomedical Communications1430 Tulane AvenueTulane Medical CenterNew Orleans, Louisiana 70112

MAINE, FARMINGTON

TITLE: Rural Health Associates: Interactive MedicalMicrowave Television (RHA)

PERIOD: 1971-Present

TECHNOLOGY: Microwave, 2-Way Audio/Video/Data

APPLICATION: Primary Care, Administration, Education

RHA, a private medical group practice in Farmington, was thefirst health care organization to include interactive tele-vision communications as an integral part of its organizationalplan-. A two-way link has been established between RHA andtwo ambulatory care satellite clinics in Rangeley and King-field. Objectives include providing comprehensive healthcare to rural areas, establishing support for health careprofessionals living away from major medical centers, andproviding these professionals with sufficient coverage toallow time for continuing education.

REFERENCE: Bashshur, R. I., P. A. Armstrong, and Z. I.Yous$ef, Eds., Telemedicine: Explorations inthe Use of Telecommunications in Health Care.(Thomas: Springfield, Illinois, 1972).(2)

CONTACT: Clinton A. ConantProject AdministratorRural Health AssociatesFarmington, Maine 04938

1?

117

MAINE, STONINGTON

TITLE: Blue Hill-Deer Isle Telemedicine Project

PERIOD: 1973-1977

TECHNOLOGY: Microwave, 2-Way Audio/Video

APPLICATION: Primary Care, Administration, Education

This project was instituted to nrovide expert consultativeservices via two-way interactive television from Blue HillMemorial Hospital to a nurse practitioner-staffed clinicin the isolated community of Stonington on Deer Isle. Thelink was also used to train Deer Isle ambulance attendantsin first aid and primary care.

REFERENCE:

CONTACT:

118

Chan, S., and J. R. Mes.ick, 33 Telecommunica-tions Projects in Medical Education and HealthCare. (Office of Medical Education, Researchand Development, Michigan State Univ9pity:East Lansing, Michigan, March 1975) .

Richard Britt, M.D.Blue Hill Memorial HospitalBlue Hill, Maine 04614

MASSACHUSETTS, BOSTON

TITLE: Nursing Home Care Program

PERIOD: 1972-Present

TECHNOLOGY: Telephone

APPLICATION: Primary Care

This is a system where Nu-se Practitioners and Physician Assis-tants provide primary medical care to 330 Boston area nursinghome patients in ten locations in the context of a primary caregroup practice affiliated with the Beth Israel Hospital. Thisprogram initially developed at Boston City Hospital demonstratedthat improved quality of medical care and accessibility couldbe provided to inner city nursing home residents with reducedreliance on the hospital and with significant cost savings.

REFERENCE: Bashshur, R. I., P. A. Armstrong, and Z. I.Youssef. Eds., Telemedicine: Explorationsin the e of Telecommunications in Health Care.(Thomab. Springfield, Illinois, 1972).(z)

CONTACT: 'pert J. Master, M.D.irector, The Urban Medical Group, Inc.

545D Centre StreetJamaica Plain, Massachusetts 02130

119

MASSACHUSETTS, BOSTON

TITLE: Massachusetts General Hospital/Logan Airport

PERIOD: 1968-Present

TECHNOLOGY: Microwave, 2-Way Audio/Video/Data

APPLICATION: Primary Care

Although currently not in operation, this system has thecapability, and was used in the past, to link a nurseclinician at Logan Airport with the physicians at Massachu-setts General in Boston, providing telediagnosis andteleconsultation services. The system was designed toprovide fuller utilization of the skills of the healthprofessionals via telecommunication's capacity to over-come the problems of accessibility and travel time in anurban setting.

REFERENCE:

CONTACT:

120

Murpr S I. , "Accuracy of DermatologicDiag :=7_s by Television." Archives ofDerr 105,833-835 (June 1972).(19)

Ker T. Bird, M.D.P- r DI'rector

Medical Service./L:.-etts General Hospital

War- .1 i4ilding275 Ch.---les StreetBoston, Massachusetts 02114

MASSACHUSETTS, BOSTON

TITLE: Massachusetts General Hospital/BedfordVeterans Administretion Hospital

PERIOD: 1970-Present

TECHNOLOGY: Microwave, 2-Way Audio/Video

APPLICATION: Primary Care, Education

Based in part on the experience gained from the MassachusettsGeneral Hospital/Logan Airport project, the Bedford linkwas established for teaching as well as teleconsultation. Ithas been utilized to teach health-related courses to communitycollege students at Bedford and provide continuing educationfor phySicians at Bedford. In furthering patient care, ithas been used in cases of psychiatric or neurological dis-orders, dermatology, speech therapy, drug abuse, and alcoholism.

REFERENCE: Bird, K. T., The Veterans AdministrationMassachusetts General Hospital TelemedicineProject. (Massachusetts General Hospital:Boston, Massachusetts, June 1974).(54)

CONTACT: Kenneth T. Bird, M.D.Project DirectorTelemedicine Medical ServiceMassachusetts General HospitalWarren Building275 Charles StreetBoston, Massachusetts 02114

121

MASSACHUSETTS, CAMBRIDGE

TITLE: Cambridge Telemedicine Project

PERIOD: 1972-1974

TECHNOLOGY: Microwave, 2-Way Audio/Video

APPLICATION: Primary Care

The Cambridge Telemedicine Project was establiEAled to employaudio-visual links to provide consultation and support fromphysicians at Cambridge Hospital to nurse practitionersproviding care at three neighborhood satellite health clinics.In each of the three clinics, one nurse practitioner usedtwo-way television. Two of the clinics had an additionalnurse practitioner who only used a telephone for consultation.

REFERENCE: Moore, G. T., et al. , "Comparison of Televisionand Telephone for Remote Medical Consultation."The New England Journal of Medicine, 292:14,729-732 (April 1975).(55)

122

MINNESOTA, WAGON IA

TITLE: Lakeview Clinic Bi- Directional Cable TelevisionSystem

PERIOD: 1972-1974

TECHNOLOGY: Cable, 2-Way Audio/Video/Data

APPLICATION: Primary Care

This system was instituted to evaluate a two-way audio-videocable link between the rural Lakeview practice clinics atWaconia and Jonathon and Ridgeview Hospital in Waconia. Amajor goal of this project was to assess the behavioral andattitudinal changes of the participating physicians andallied health pe-rsonnel and the care of the patient partici-pating in the health carte process and the telehealth link.The system was used for teleconsultations, telediagnosis,monitoring, and augmented verbal communication-follow-up exams.Data transmissions, including EKGs, x-rays, and charts, wereperformed.

REFERENCE:

CONTACT:

Lasden, G., Ed., Improving Ambulatory HealthCare Delivery. (Lexington Books, D.C. Heath andCompany: Lexington, Massachusetts, 1977)-(56)

Jon Wempner, M.D.Lakeview Clinic Group200 West Highway #5Waconia, Minnesota 55387

e

t

123

MISSOURI, ST. LOUIS

TITLE: Veterans Administration Nuclear Medicine Project

PERIOD: 1974-Present

TECHNOLOGY: Telephone, Computer

APPLICATION: Primary Care

It is the into-- =- ,:+f this system to provide nuclear medicineservices of t-e -z-ge-city Veterans Administration Hospitalat St: Louis t(- Veterans Administration hospitals in arural area outside of St. Louis, in southern Illinois, andin southern Missouri. Each hospital is equipped with acomputer and gamma camera, operated by a trained technician.Each day patient studies are recorded and stored on magneticdisks. At the end of the day the technicians at the remotehospitals re-format the data into picture format and transmitit via data phones to the main computer at the St. LouisVeterans Administration hospital. From these images,diagnoses are determined and reports are transmitted thenext morning to the three rural hospitals.

RFFERENCE: Annual Report: Exchange of Medical InformationProgram, Fiscal Year 1976. (Veterans Administra-tion, Department of Medicine and Surgery,Learning Resources Service: Washington, D. C.,August 1976) .

(42)

CONTACT:

124

Robert Donati, M.D.St. Louis Veterans HospitalSt. Louis, Missouri 63125

NEBRASKA, MULLEN

TITLE: Rural Initiative Health Grant

PERIOD: 1976-1979

TECHNOLOGY: Telephoto Transmitters, Radio, Telephcne

APPLICATION: Primary Care

Only one of the seven counties included in this project hada physician prior to the project's inception. The projectplans to provide services through both a home health careservice program and two satellite clinics. A biocommunica-tions network is also proposed, including telephone communi-cations to link existing area medical centers and the newclinics.

REFERENCE: Anderson, C, and W. Rappaport, TechnologyApplications in Rural Health Care Systems.MTR-7537 (The Mitre orporation: McLean,Virginia, May 1977).(C27)

ADDITIONAL REFERENCE SUGGESTED BY PROJECT:

CONTACT:

Baxter, W. E., Dr. P.H., "A Substitute Systemfor Rural Health Care." Hospital and HealthServices Administration. 22:3 (American ro/legeof Hospital Administrators: Chicago, 1977).(75)

Wesley MoenchDirectorSandhi Its Development CorporationMullen, Nebraska 69152

L.)

125

NEBRASKA, OMAHA

TITLE: University of Nebraska Medical Center

PERIOD: 1959-Present

TECHNOLOGY: Microwave, 2-Way Audio/Video

APPLICATION: Primary Care, Education

The 1niversity of Nebraska Medical Center began using two-way closed- circuit television in 1959 to transmit educationaldemonstrations with neurological patients and case informationfrom the Nebraska Psychiatric Institute (NPI) to medicalstudents in the Department of Anatomy. From 1964 to 1969 a112-mile link was active between NPI and Norfolk State MentalHospital to facilitate joint conferences, to improve patientcare at the isolated Norfolk health facility, and to carryout collaborative psychiatric projects. Since 1970 theMedical center has been linked with three Veterans Administra-tion hospitals, a dental school, and a medical school toprovide education and training in a wide variety of medicalspecialty areas. In 1976 the Omaha and Lincoln campusesof the University of Nebraska School of Nursing were linkedto provide sharing of faculty and instructive material.

REFERENCES: Annual Report: Exchange of Medical InformationProgram,. Fiscal Year 1976. (Veterans Adminis-tration, Department of Medicine and Surgery,Learning Resources Service: Washington, D. C.,August 1976). (42)

Wittson, C., M.D., and R. Benschoter, M.S.,"Two-Way Television: Helping the MedicalCenter Reach Out." American JournO. of Psy-chiatry, 129:5 (November 1972).0"

ADDITIONAL REFERENCES SUGGESTED BY PROJECT:

CONTACT:

126

Benschoter,R.. "Multi- Purpose Television."Annals of the New York Academy of Sciences,142:2, (March 1967).(5110

Cecil Wittson, M.D.Chancellor EmeritusUniversity of NebraskaMedical Center42nd and DeweyOmaha, Nebraska 68105

NEBRASKA,, OMAHA

TITLE: Remote Radiographic Transmission for DiagnosticInterpretation

PERIOD: 1973-1975

TECHNOLOGY_: Microwave, Cable, 2-Way Audio, 1-Way Data(x-rays), Telephone

APPLICATION: Primary Care

This project was designed to provide on-demand interpretationof x-rays transmitted between the small rural community ofBroken Bow, which had no radiologist, and the Department ofRadiology ,of the University of Nebraska Medical Center. Thepurpose was to implement and evaluate a slow-scan systemfor transmitting x-rays.

REFERENCE: Chan, S., and J. R. Messick, 33 Telecommunica-tions Projects in Medical Education and HealthCare, (Office of Medical Education, Researchand Development, Michigan'State University:East Lansing, Michigan, March 1975)-(45)

CaNTACT:, William J. Wilson, M.D.Memorial Hospital Medical Center2801 Atlantic AvenueLong Beach, California 90806

127

13:

NEW HAMPSHIRE, HANOVER

TITLE: New Hampshire/Vermont Interactive MedicalTelevision Network (Interact)

PERIOD: 1968-Present

TECHNOLOGY: Microwave, 2-Way Audio/Video/Data and Videotape

APPLICATION: Primary Care, Administration, Education

Interact developed from a 1968 link between Dartmouth-Hitchcock Medical Center, Hanover, New Hampshire, and theClaremont General Hospital, Claremont, New Hampshire. Bylate 1972 the network also included the University ofVermont Medical Center at Burlington, the Central VermontMedical Center at Montpelier, the Rockingham Memorial Hospital,and the Windsor Prison. Additional links are beingestablished in both states with current construction oflinks at the White River Jct., Vt. Veterans AdministrationHospital and the St_ Albans, Vt. Correctional Facility. Thesystem seeks to provide medical services to communitiesthat have had only limited access to specialty care and topool faculty resources between institutions involved inhealth manpower training to optimize the use of professionals.Services include patient consultation, specialty conferences,continuing education, Grand Rounds and joint faculty/student programs. As an adjunct to the two-way microwavenetwork, Interact/Media Outreach provides videotapes of"airtime" programs on a loan basis to region'al hospitalsnot interconnected with the Interactive Television Network.

REFERENCE: Siebert, D. J., A D=.rade of Experience UsingTwo-Way Closed Circuit Television for MedicalCare and Education. Final Report, Contract#1 -LM-4 -4704 (Lister Hill National Center forBiomedical Communications, National Libraryof Medicine: Bethesda, Maryland, November (-

CONTACT:

128

Marshall KrumpeNetwork ManagerINTERACT Televisionc/o Dartmouth-Hitchcock Medical_ CenterHanover, New Hampshire 03755

1")

NEW MEXICO, CUBA

TITLE: Checkerboa,.7,1 Area Health System

PERIOD: 1973-Present

TECHNOLOGY: Radio, Telephone

APPLICATION: Primary Care, Administration

The Checkerboard Area Health System was established to improvehealth care services to the largely Navajo population north-

, west of Albuquerque. The system links a Health Center in Cubawith six outreach clinics staffed by non-physician providers.The Health Center has a nine-bed hospital, outpatient facilities,an emergency room, and dental services. It provides consultativeservices and administrative support to the satellite clinics.The outreach clinics provide services on an outpatient basis andthrough a home health visit program.

REFERENCE: Cuba-Checkerboard Area Coordinated Health Program:A Model for a Health Delivery System in aDistressed Rural Area of New Mexico. (Presbyterian

(60)Medical Services: Santa Fe, New Mexico, July 197T1:

CONTACT: David A. WatsonSystem AdministratorCheckerboard Area Health SystemP.O. Box 638Cuba, New Mexico 87013

NEW MEXICO, PLAYAS LAKE

TITLE: Playas Telehealth System

PERIOD: 1975-Present

TECHNOLOGY: Microwave, 2-Way Audio/Video, Telephone,Facsimile

APPLICATION: Primary Care, Administration

The Playas Telehealth System installed under the directionof the University of New Mexico and financed by the PhelpsDodge Corporation, was designed to provide comprehensivehealth care to over five hundred workers and their dependentswho live at the Phelps Dodge Corporation copper smeltingtownsite of Playas, New Mexico. Playas Clinic, operatedby physician extenders, is linked to Med Square Clinic inSilver City where physicians are available to supply awide range of services via telecommunications to the PlayasClinic. These services include consultation, diagnosis, andadministrative support. Playas and surrounding communityresidents now have a broad base of health servicesavailable to them, including primary care, emergency care,laboratory/x-ray services, and pharmaceuticals.

REFERENCE: Playas Lake Telehealth System - Phase IReport. (University of New Mexico RegionalHealth Program: Albuquerque, New Mexico ,

December 1975). (61)

CONTACT:

130

Shelby King, M.D.Med Square Clinic114 W. 11th StreetSilver City, New Mexico 88061

It

NEW YORK BUFFALO

TITLE: Communications In Learning Tele-lecture Network

PERIOD: 1968-Present

TECHNOLOGY: 2-Way Audio, Darome "Meeting Bridge"

APPLICATION:, Education

The Tele-lecture Network is a two-way communications systemlinking more than forty hospitals, presently within a 200mile radius, in Western New York State, Northeastern Pennsyl-vania, and Ontario, Canada, to provide educational programs,both for credit and for non-credit continuing education.Seventeen different program areas are offered, includingnursing, surgery, speech therapy, dietetics, medical technology,medical records, and others. Programs generally consist oftwo one-half hour sessions. During the first one-half hour,the presentation by the instructor is transmitted from theCommunications In Learning Resource Center to the participatinghospitals. Questions are then transmitted back from the hospitalsto the instructor during the second one-half hour. Each seriesis sponsored by a professional society or organization. Pro-fessionals in their fields from all over the country are invitedto participate as instructors on a no-fee basis, as CommunicationsIn Learning, Inc., is now operating as a non-profit organization.The programs are then taped and described in a catalog whichcan be purchased.

REFERENCE: Individuals Working Together for Creative Action.

CONTACT:

(Communications o,(inN-Learning, Tnc.: SutraNew Yoric,1977). 621

Emmett C. Murphy, M.D.President, Communications in Learning, Inc.2929 Main StreetBuffalo, New York 14214

131

NEW YORK, NEW YORK

TITLE: East Harlem Broadband Health CommunicationsNetwork (Mt. Sinai)

PERIOD: 1972-1975

TECHNOLOGY: Cable, 2-Way Audio/Video, 1-Way Audio/Video

APPLICATION: Primary Care, Administration, Health Education

This system was composed of two community projects. One wasa two-way interactive audio/video link to provide pediatricservices from Mt. Sinai Hospital to a nurse practitioner atthe Wagner House's Child Health Station. The second projectused closed-circuit television to provide health and communityinformation to over three hundred elderly residents of theGaylord White Housing Project. Objectives of the projectincluded determining the degree of acceptance of bi-direc-tional cable television by both health providers and con-sumers, the effectiveness of bi-directional video and audiocontact in lieu of in-person physician/patient contact, andcost-benefits of the system.

REFERENCE: Selzer, J. E., C. L. Marshall, and E. R. Glazer,"The Use of Cable Television as a Tool inHealth Education of the Elderly: Screenings,"Health Education Mon graphs (Office ofPrimary Health Care Education, College ofMedicine and pencistry: Newark, New Jersey,Winter 1977).`3/

ADDITIONAL REFERENCE SUGGESTED BY PROJECT:

CONTACT:

132

Muller, C. et al. , "Cost Factors in UrbanTelemedicine." Medical Care, 15:3 (March 1977). (64)

Carter L. Marshall, M.D.DirectorOffice of Primary Health Care EducationCMD/NJ100 Bergen StreetNewark, New Jersey 07103

OHIO, CLEVELAND

TITLE: Telemedicine Project at Case Western Reserve University

PERIOD: 1972-1978

TECHNOLOGY: Laser, Cable, 2-Way Audio/Video/Data

APPLICATION: Primary Care

This project was instituted to link an operating room at Cleve-land Veteran's Administration Hospital and an anesthesia moni-toring room at University Hospitals, Case Western Reserve. Theconsultant at the University Hospitals may view the patient,anesthetizing area, and operating room at the Veteran'sAdministration Hospital on a color television monitor and m.converse with the anesthetist. The initial overall objectivewas to evaluate the use of two-way, audio/video data communi-cations as a potential remedy to the shortage of anesthesiologists.This- objective was expanded to explore the utility of tele-medicine in furthering the regionalization of medical care. Alink to Forest City Hospital in the inner city was added in 1975,connecting the intensive care unit and the newborn nursery with theconsultative and supervisory capabilities of Uriversity Hospital.An overall declining census of FCH saw the closure of the ICUin late 1976, which terminated that aspect of the project.Because of its continuing gross inability to compete success-fully as a secondary and tertiary patient care facility, FCHclosed February 6, 1978. Consequently all clinical telemedicineactivities have ceased. The newborn nursery project effort whichis now in the process of final evaluation promises to be the mostsuccessful aspect of the project from the patient outcome pros-pective. FCH is considering the role of a primary health careprovider. If this becomes a reality, it is conceivable thattelemedicine can be utilized on site as a consultative andsupervisory tool in patient care as well as expedite patienttriage to appropriate health care facilities. -There will becontinued anesthesia consultation via telemedicine to theVeteran's Administration Hospital.

REFERENCES: Gravenstein, J. S., Laser Mediated Telemedicine,Final Report. (Case Western Reserve University:Cleveland, Ohio, December 1973).(55)

Grundy,13. L., et al., "Telemedicine in CriticalCare: An Experiment in Health Care Delivery "Journal of the American Colleee of EpergengyPhysicians, and The University Association for

(66)Emergency Medicine, 6:10,439-444 (October 1977).

133

CONTACT: J. S. Gravenstein, M.D.Professor and DirectorDepartment of AnesthesiologySchool of Medicine, Case Western University2119 AbingtonCleveland, Ohio 44106

134

OHIO, COLUMBUS

TITLE: Ohio Valley Medical Microwave Television System

PERIOD: 1974-Present

TECHNOLOGY: Microwave, 2-Way Audio/Video

APPLICATION: Education, Primary Care, Administration

Designed originally to provide tele-diagnosis and tele-consul-tation to improve the health services in Ohio's AppalachianRegion, this system has evolved to providing continuing medicaleducation for physicians, nurses, allied health professionalsand undergraduate medical students. The system links sixstations serving seven southeastern counties. The teaching-treatment centers of Ohio State University College of Medicineand in 1978 Ohio University College of Osteopathic Medicine arelinked with rural town and state hospitals. Applications forwhich the system is used include continuing medical educationof professionals, in-service training, training of alliedhealth personnel, consultation and diagnosis, training of under-graduate medical students at remote training sites, administrativecommunication and data exchange. The system is a project of theOhio Educational Television Network Commission and is operatedby Ohio University.

REFERENCE: Char,S., and J. R. Messick, 33 TelecommunicationsProjects in Medical Education and Health Care.(Office of Medical Education, Research and Develop-ment, Michigan State University: East Lansing,Michigan, March 1975).(45)

CONTACT: Ronald A. BlackProject DirectorOhio Valley Medical Microwave Television System353 Grosvenor HallAthens, Ohio 45701(614) 594-6401

135

OREGON, EUGENE

TITLE: McKenzie River-Health Clinic

PERIOD: 1976-1979

TECHNOLOGY: Slow-scan Television

APPLICATION: Primary Care, Administration

The purpose of this project is to establish the McKenzieHealth Clinic for providing health services to themedically underserved population of the McKenzie RiverValley. The clinic is staffed by physician extenders whouse a two-way slow-scan television system for consultationswith physicians of a hospital in Eugene.

REFERENCE: Rappaport, 14., and F. Skinner, Developmentand Implementation of the McKenzie ClinicTelehealth System. MTR-7715 (The MitreCorporation: McLean, Virginia. In Press). (67)

CONTACT:

136

Ronald CastleLane County McKenzie River ClinicP.O. Box 183Blue River, Oregon 97413

RHODE ISLAND. BLOCK ISLAND

TITLE: Rhode Island Rural Vealth Demonstration Project

PERIOD: 1976-1979

TECHNOLOGY: Slow-scan Television

APPLICATION: Primary Care

The Rhode Island project is designed to provide comprehensivecare to the populations of the medically underserved towns ofGlocester and Scituate, Richmond and Charleston, and BlockIsland. The first two areas are served by mobile vans offeringa variety of services. Block Island, medically isolated fromthe mainland, is linked to a mainland hospital via slow-scantelevision to permit voice communication and transmission ofx-rays, EKGs, and body views for specialty consults.

REFERENCE

CONTACT:

,paport, W., and F. Skinner. The Block _Island-Island Hospital Tel, Cstern: A Pro

grs Report. WP12787 (Thy ____ Corporation:McLean, Virginia, January 1978).(73)

Frank DonahueRhode Island Department of Health75 Davis StreetProvidence, Rhode Island 02908

137

SOUTH CAROLINA, HAMPTON (HAMPTON COUNTY)

TITLE: Improving Rural Health Care: A Computer-Based Health Communications System

PERIOD: 1976-1979

TECHNOLOGY: Computer

APPLICATION: Primary Care, Administration

This project was designed to establish an organized computer-based system for the communication of patient informationamong providers in Hampton County. The main computer,located in Hampton General Hospital, is linked with remoteterminals o7)erated by physicians, pharmacists, and otherhealth providers in the County. A computerized billingsystem has also been developed.

REFERENCE:

CONTACT:

138

"The Hampton Project: Initial Census Datafor a Community-Based Health CommunicationSystem." Journal of the South CarolinaMedical Association (October 1977).(68)

Harrison L. Peeples, M.D.ChairmanHampton County Health Foundation, Inc.Hampton General HospitalVarnville, South Carolina 299-44

TEXAS

TITLE: Interactive Closed-Circuit Television System

PERIOD: 1974-Present

TECHNOLOGY: Microwave, Cable, Closed-Circuit Television

APPLICATION: Primary Care, Administration, Education

This system was designed tc link three Veterans Administrationhospitals wit--in an area of Texas. called the "Mini-Region."Each hospital also has its own in-house, closed-circuittelevision system. The microwave system linking the threehospitals is used for medical consultations and joint admin-istrative conferences. One of the hospitals is also linked bycable to a non-Veterans Administration hospital to facilitatesharing of lecture materials.

REFERENCE: STARPAHC Systems Report, 2 vols. (NationalAeronautics and Space Administration, JohnsonSpace Center: Houston, Texas, Contract No.NAS9-13170, LMSC D566138, October 1977).(43)

CONTACT: Mr. Robert B. ShamaskinDeputy DirectorLearning Resources Service (142 A)Department of Medicine and SurgeryVeterans Administration810 Vermont Avenue, N.W.Washington, D. C. 20420

139

UTAH, SALT LAKE CITY

TITLE: Utah Remote Site Rural Health Program

PERIOD: 1976-1979

TECHNOLOGY: Computer

APPLICATION: Primary Care, Education

This project was initiated to provide primary medical carein two underserved rural areas in Utah. The satelliteclinics are staffed by physician extenders linked withphysicians by computerized medical audit protocol toensure consistently high quality services. Co=puters arelocated in the remote sites with linkages via telephoneto backup physicians locaed at Salt Lake City and Rich-field. Primary care, preventive medicine, and mental healthservices are provided by the clinics. The computers alsomaintain medical records and a financial management systemfor each clinic.

REFERENCE:

CONTACT:

140

Anderson, C, and W. Rappaport, TechnologyApplications in Rural Health Care Systems.MTR-7537 (The Mitre orporation: McLean,Virginia, May 1977).(C27)

Donna Olsen, Ph.D.Assistant ProfessorUniversity of UtahColleip of Medicine50 N. Medical DriveSalt Lake City, Utah 84132

VERMONT, GRAND ISLE COUNTY

TITLE: Grand Isle County Integrated Heath ServicesProject

PERIOD: 1976-1979

TECHNOLOGY: Telephone

APPLICATION: Primary Care

The objective of this project is to provide a comprehensive,integrated, 24-hour health care system to isolated Grand IsleCounty in eastern Vermont. The Champlain Islands HealthCenter, the focal point of the project, is staffed by nursepractitioners. Physicians make periodic on -site. visits.Using the telephone number of the Champlain Center, a 24-hourcall system has been developed which 'refers calls to physiciansafter they are screened-by specially trained local residents.

REFERENCE:

CONTACT:

Anderson, C.,and W. Rappaport, TechnologyApplications in Rural Health Care Systems.MTR-7537 (The Mitre Corporation: McLean,Virginia, May 1977).(27)

Elizabeth J. DavisVisiting Nurse Association260 College StreetBurlington, Vermont 05401

151

141

WASHINGTON_,_ SEATTLE

TITLE: WAMI (Washington, Alaska, ,ntana, Idaho)

PERIOD: 19 74 -19 75

TECHNOLOGY: Satellite, 2-Way Audio/Video/Data

APPLICATION: Primary Care, Administration, Education

This project utilized the ATS-6 satellite for long distancetraining of University of Washington medical students. Two-way live broadcasts were beamed between the University ofWashington and Fairbanks, Alaska, and Omak, Washington.The first quarter of the university's medical school trainingwas taught at the University of Alaska, Washington StateUniversity, University of Idaho, and Montana State Uni-versity. This project was designed to educate more doctorsand encourage them to practice in rural areas. Videoand audio transmission were also used to provide administra-tive conferencing between officials at all locations.

REFERENCES:

CONTACT:

142

Dohner, C. W., T. J. Cullen, and E. A.Zonser, ATS-6 Satellite Evaluation: TheFinal Report of the Communications SatelliteDemonstration. (University of WashingtonSchool of Medicine: Seattle, Washington,September 1975).(21)

Schwarz, M. R., and M. H. Johnson, "Roleof SatelliZ:. Broadcasts in RegionalMedical Education and Health CareDelivery." AIAA Conference on Communica-tions Satellites for Health/EducationApplications, Denver, July 1975.

Roy Schwarz, M.D.WAMI DirectorUniversity of WashingtonSchool of MedicineSeattle, Washington 9P195

WISCONSIN, MADISON

TITLE: Nursing Dial Access Library

PERIOD: 1968-Present

TECHNOLOGY: Telephone (for Tape Library Access)

APPLICATION: Primary Care, Education

Presently, this system hosts a library of about four hundred,four to seven-minute tape recordings on a variety of medicaland nursing subjects. The service is available twenty-fourhours a day, seven days a week and is open to registerednurses throughout Wisconsin. It is also available by contractto Veterans Administration hospitals and National Health ServiceCorFs physicians and nurses around the country. Participatinghealth professionals receive a c-talog listing of the tapesand their respective numbers. A person wishing to use the service,dials the library at the University of Wisconsin Medical Centerand the operator who answers selects and plays the requestedtape.

REFERENCE: Annual Report: Exchange of Medical InformationProgram, Fiscal Year 1976. (Veterans Administra-tion, Department of Medicine and Surgery, LearningResources Service: Washington, D. C., August 1976). (42)

CONTACT: Ann Niles, R.N.424 Lowell Hall610 Langdon StetMadison, Wisconsin 53706

NOTE: We have decided Lo terminc-.te the service forWisconsin Physicians during the coming year, butcontinue it for nurses. Over the last few yearsfewer doctors have subscribed and used the service.

CANADA, NEWFOUNDLAND, ST. JOHN'S

TITLE: Experimental Use of the Communications Tech-nology Satellite Hermes in Telemedicine

PERIOD: March 1977-June 1977

TECHNOLOGY: Satellite, One-way TV, Audio Teleconferencing

APPLICATION: Education

The goal of the experiment was to test the satellite systemas a means of providing continuing education to physicians,nurses and allied health workers at 4 hospitals in theprovince. The topic included Communications/DevelopmentDisorders in Children, Cardiology, Anesthesia, Thera-peutics, various areas in nursing and community healtheducation, as well as sessions in hospital administration.The project simulated various sessions at St. John's betweena hospital and the teaching centre. In the post-Hermesexperiment phase the project office is exploring teachingand consultation applications of the existing telephonenetwork, using at times facsimile and slow-scan technology.

REFERENCE: House, A. M., and W. C. IrcNamara, Report onMemorial University of the CommunicationsTechnology Satellite Hermes in Telemedicine.(Health Sciences Centre, Memorial University:St. John's, Newfou,dland, 1977).(69)

CONTACT:

144

Dr. Maxwell HouseAssistant DeanContinuing Medical EducationMemorial University

. St. John's Newfoundland A1C 5S7

CANADA, ONTARIO, LONDON

TITLE:

PERIOD:

TECHNOLOGY:

APPLICATION:

Canadian Telemedicine Experiment U-6

October 1976-February 1977

Satellite, One-way Video, Two-way Audio, Facsimile,1-Way Data

Professional Supervision and Support,Primary Care

The Hermes Communications Technology Satellite linked a remcteBase Hospital via one-way TV plus interactive audio and facsimileto the University Hospital. Further, a nursing statf.on waslinked via interactive audio and facsimile to the Base Hospitalto support primary care of the nursing station. The camera at theBase Hospital was controlled remotely from the UniversityHospital. TV link was used for support of practicing physiciansand specialists at the Base Hospital in the areas of radiology,anesthesia, psychiatry, cardiology, pathology, hematology,physiotherapy, dentistry, pharmacy, respiratory technology,nursing support, infection control and administration. Theexperience gained and information gathered in the experimentwill be applied to future developments in regard to telehealthcare systems in Canada.

REFERENCES: Carey, L. and E. Russell, Canadian TelemedicineExperiment U-6 (Universvof Western Ontario:London, Ontario, 1977)-'

CONTACT:

Roberts, R., S. Skene, and G. Lyons, Evaluationof the Moose Factory Telemedicine Project U-6(McMaster University: Hamilton, Ontario 1978).(71)

Dr. Lewis S. CareyExperiment LeaderDepartment of Diagnostic RadiologyUniversity of Western OntarioLondon, Ontario

15.3145

CANADA, TORONTO

TITLE: University of Toronto/University of Waterloo'"elemedicine Project

PERIOD: September 1977-September or December 1979

TECHNOLOGY: Telephone, Slow-Scan Video

APPLICATION: Primary care

This is a study of the cost-effectiveness of a slow-scanvideo system in assisting delivery of health care toNorthwestern Ontario. The telephone system links twentyHealth Aid Stations, seven Nursing Stations, one BaseHospital at Sioux Lookout, Ontario, and two ConsultingHospitals in Toronto. Slow-scan video links one Base Hospital.one Health Aid Station, two Nursing Stations, and twoConsulting Hospitals. Normal telephone lines, satellitelines, radio telephone and radio are used. Slow-scan videosystems have teen installed at six sites and are plannedfor communities but await installation of the requiredtelephone lines. The study will compare health caredelivery patterns in communities with slow-scan video equip-ment and communities without the equipment. Patient careand telecommunication data is being collected from allprofessional/patient encounters in the northern communities,representing essentially a census of primary health caredelivery in the region. Cost-effectiveness is expected tobe related to patient transfer. After the first six months.of the project several health professionals have be -.n

trained to operate the slow-scan systems without assistance7data collection and coding procedures are satisfactory.Sufficient data to begin testing hypotheses should be avail-able after 12 to 18 months of data collection.

REFERENCE:

CONTACT:

146

Dunn, E. V., and D. W. Conrath, TelemedicineProject: 1977 Year End Report. (Universityof Toronto: Toronto, Ontario).(72)

Earl V. Dunn, M.D.Department of Family and Community MedicineUniversity of TorontoToronto, Ontario

David W. Conrath, Ph.D.Department of Management SciencesUniversity of WaterlooWaterloo, Ontario

1 5

REFERE::rES

1. Park, B., An Introduction to Telemedicine: Interactive Televisionfor Delivery of Health Services. (The Alternate Media Center atthe School of the Arts, New York University: New York, June 1974).

2. Bashshur, R. I., P. A. Armstrong, and Z. I. Youssef, Eds.,Telemedicine: Explorations in the Use of Telecommunications inHealth Care. (Thomas: Springfield, Illinois, 1972).

3. Rockoff, M., "An Overview of Some Technological/Health Care SystemImplications of Seven Exploratory Broadband Communications Experi-ments." IEEE Transactions on Communications. COM-23,1,20-30(January 1975).

4. Doermann, A. C., D. MacArthur, and P. Walcoff, Extending theCapabilities of Non-Physician Providers in Isolated Rural Areas:An Investigation of the Potential Impact of Telecommunications-Based Technology. MTR-7063 (The Mitre Corporation: McLean,Virginia, June 1976).

5. Anderson, C., and P. Walcoff, A Preliminary Plan for a Demonstra-tion of Rural Health Care Telecommunications Linkages in AppalachiaKentucky. YTR-7274 (The Mitre Corporation: McLean, Virginia,June 1976).

6. Elton, M. C. J., "The Use of Field Trials in Evaluating Tele-medicine Applications." Telemedicine: Explorations in the Useof Telecommunications in Health Care, R. T. Bashshur, P. A.Armstrong, and Z. I. Youssef, Eds. (Thomas: Springfield,Illinois, 1972).

7. O'Neill, J. J., C. A. PaquetL,:, and S. Polk, Testing the Applica-bility of Existing Telecommunications Technology in the Administra-tion and Delivery of Social Services. M-73-52 (The Mitre Corpora-tion: McLean, Virginia, April 1973).

8. Neham, E., A Telephone Network Enabling the Provision and Manage-ment of 24-Hour Medical Care Services in Isolated Rural Areas.WP-11633 (The Mitre Corporation: McLean, Virginia, July 1976).

9. Rasmussen, W. T., and J. Silva, Navy Remote Medical DiagnosisSystem- (Naval Electronics Labaratory Center: San Diego,California, 197o).

O. Skinner, F. L., Technology Support of the Remote Non-PhysicianProvider: Telecommunications Systems and End-InstrumentComponents. M76 -81 (The Mitre Corporation: McLean, Virginia,December 1976).

147

15.-

11. Reid, R. A., "An Analysis of Tasks Performed by Mid-Level HealthProfessionals in an Experimental Rural Medit.-:al Care DeliverySystem." Abstract Proceedings of the First Miami InternationalConference: Progress and Prospects in Health Care DistributionSystems, (National Science Foundation: Washington, November 1974_

12. Henry, R. A., "Evaluation of Physician Assistants inCounty, Florida." Abstract Proceedings of the FirstInternational Conference: Progress and Prospects inDistribution Systems, (National Science Foundation:.N ,ember 1974).

GilchristMiamiHealth CareWashington.

13. Klapper, M. S., and I. B. Harper, "MIST--Observations andTrends." Journal of the Medical Association of the State ofAlabama (April 1975).

14 Drazen, E., J. Metzger, and K. Wiig, Automated Electrocardiographyin the United States. (Arthur D. Little, Inc.: Cambridge,Massachusetts, August 1976).

15. Mesel, E., and D. D. Wirtschafter, "On-Line Medicaid Billing Systefor Physicians' Services." Computers and Biomedical Research.8,479-491 (1975).

lb. Laudet, J., J. Anderson and F. Begon, Eds., Medical Data Processin(Taylor and Travers: London, 1976).

17. Barnett, G. O., "ComplIter-Stored Ambulatory Record (COSTAR)."NCHSR Research Digest Series, (HRA) 76-3145 (U. S. Departmentof Health, Education and Welfare: Washington, D. C., 1976).

18. Coulson, John E., "Computer-Assisted Instruction and ILs Potentialfor Individualizing Instruction." To IM7 ve Learning: An Evaluation of Instructional Technology, Sidney _ Tickton, Ed. (Bowker:New York, 1970).

19. Murphy, R. I., "Accuracy of Dermatologic Diagnosis by Television."Archives 'f Dermatology. 105,833-835 (June 1972).

70. Boor, J. L., G. Braunstein, and J. M. Janky, "ATS-6: TechnicalAspects of the Health/Education Telecommunications Experiment."IEEE Transactions on Aerospace and Electronic Systems. AES -Il,6,1015-1032 (November 1975).

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22. White, P. B., Satellites, Telecommunications and Education- -A Calendar of Future Events. (Syracuse Uni,: -sity ResearchCorporation: Syracuse, New York, January 176).

23. Progress Report: Evaluation of Remote Radiographic Communica-tions January, 1974 - January, 1975. (University of NebraskaMedical Center. Omaha, Nebraska, 1975).

24. Video Kequirements for Remote Medical Diagnosis. (SCI Systems,Inc.: Houston, Texas, June 1974).

25. Per:4L.:na1 communication with Dr. Ralph E. Adams. (Oklahoma City,Oklahoma, June 1077).

26. Dhillon, H., and A. M. Bennett, A Cost-Performance Analysisof Alternative Manpower Technology Combinations for Delivering,Primary Health Care. MTR-7068 (The Mitre Corporation: McLean,Virginia, October 1975).

27. Anderson, C.. and W. Rappaport, Technology Applications in RuralHealth Care Systems. MTR-7537 (The Mitre Corporation: McLean,Virginia, May 1977).

28. Personal communications with Dr. Stuart Meyer. (NorthwesternUniversity: Evanston, Illinois, 19-7) .

29. Personal communications with Dr. Anthony J. Pippo. (Marine Medi-cal Service, Inc.: Sar Diego, California, 1977).

30. O'Neill, J. J., J. T. Nocerino, and P. ';._.:1coff, Benefits andProblems of Seven Exploratory Telemedicine Projects. MTR-6787(The :litre Corporation: McLean, Virginia, February 1975) .

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32. Doernann, A. C., S. N. Goldstein,and D. L. MacArthur, et al.,Selected Approaches to Enhancing the Retention of Primary CarePhysicians in Rural Practice. YTP-7069 (The 'Mitre Corporation:McLean, Virginia, October 1975).

33. -Bennett, A. M., Assessing the Performance of Pural Primary HealthCare Systems. MTk -6788 (The Mitre Corporation: McLean, Virginia,November 1974).

34. Walcoff, P., J. T. Nocerino, and D. L. MacArthur, et al., AnInvestigation of Health Manpower Reources for rural Primary CareDelivery. MTR-6918 (The Mitre Corporation: McLean, Virginia,August 1975).

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36. skinner, F. L., Telehealth Technology: A Laboratory Report.M.1-7697 (The Mitre Corporation: McLean, Virginia, October 1975

37. Rackoff, M. L., and A. M. Bennett, "The 'Patient Trajectory':A Modeling Tool for Planning and Evaluating Rural TelemedicineSystems." (Delivered at NATO Telecommunications Symposium: PerItaly, September 1977). To be published by Plenum Publi!.lingCompany.

Mese', E., and D. D. Wirtschafter, "Autom,.ti()n of a PatientMedical Profile from Insurance Claims Dat.:1 A Possible First St._in Automating Ambulatory Medical Records on a National Scale."Health and Society. 29-45 (Winter 1976).

39. Mesel, E., and D. D. Wirtschafter, "EconoEgic Analysis of an Auto-mated Billing System for Physicians' Servic.es." Medical Care.14:1037-1051 (1976).

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STAPAIIC Systems Report, 2 vols. (National Aeronautics and SpaceAdministration, Johnson Space Center: Houston, Texas, Contract

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Mitre Corporation: McLean, Virginia, January 1978).

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