By Roy Schoenberg MD, February 15, 2011  —  As billions of dollars are budgeted to reform health care, legislators in Washington are frantically looking for ways in which the money can truly change the broken health care system without too much of an upset to its key constituents: payers, providers, employers and patients. As in most industries, modernization by the (government-sponsored) introduction of technology sounds like the safe choice. Surprisingly, forcing physicians to implement electronic medical records and to share these records via statewide exchanges is facing a daunting practice to practice “docfight.” With the unpleasant possibility of an unrealized promise for change, some suggest we turn the light on the other sleeping elephant in the room — telemedicine. Brush the dust off this misunderstood (and often misused) technology and health care reform may just live up to its promise, in our lifetimes.

Simply defined, telemedicine refers to the delivery of medical care using telecommunications including: phone, email, Internet and other channels. Over the years, the application of telemedicine was interpreted narrowly to mean the use of technology to overcome physical distance. Specifically, it became synonymous with the use of video conferencing to bring the expertise of specialized physicians (who typically reside in urban America and work in large medical centers) into rural areas where such specialties were scarce or absent. While the supporting technologies have evolved, from ISDN lines to dedicated fiber optics, the principal promise (prejudice) of telemedicine remained frozen in time.

Then came the Internet, introducing the liberating notion that any two places, any two devices, indeed any two people, can connect, reliably and instantly. Armed with the Internet, telemedicine has quickly dropped the expensive dedicated conferencing lines, and swapped them with inexpensive cable modems. Telemedicine could now accomplish the same result for fewer dollars — an excellent incentive for growth. But, (author is now pointing to an elephant in the room H.P.) looking at the Internet as a cheaper way to do the same thing is perhaps as naïve as thinking of email as a mere replacement to paper mail and a good way to save on stamps. Yes, the Internet can save some cash in connecting two points (e.g. our two physicians), but its promise lies in that it can connect any two points.

So what can we expect if we wake our dormant telemedicine by allowing it to take advantage of the true networked capability of the Internet? By reaching patient’s homes, access to medical care will start equalizing across geographies. The variations in its quality will diminish. Primary care physicians could summon specialists to help care for the patients sitting in front of them in their exam room. Physician offices can expand services by tapping allied providers they could otherwise not afford to keep on staff (e.g. nutritional services, sleeping disorders, etc.). The stigma of entering the office of a mental health provider will not keep patients away, as they can engage the therapist routinely, from the intimacy of their homes.

It can allow us physicians to care for patients in Haiti during our lunch break in the office. Fundamentally, we can expect the paradigm to change. Health care goes to where the patient is.

Patients can be discharged home earlier after surgery and still be followed during their surgeon morning rounds from the hospital. Live health care can be available in pharmacies, workplaces, airports and handhelds. It can bring additional physicians into crowded emergency rooms to help with triage; it can allow the military to project broader health care to where the troops go. It can allow us physicians to care for patients in Haiti during our lunch break in the office. Fundamentally, we can expect the paradigm to change. Health care goes to where the patient is.
This vision is far from pie in the sky. In fact, it’s starting to become a reality in communities across the country. For example, the U.S. Department of Veterans Affairs (the VA) has been enlisting a growing number of telemedicine technologies to help Americans discharged from the armed forces to manage diabetes, high blood pressure and other physical and mental health issues from their homes. Health companies, too, are making networks of providers available to their consumers online, extending care into homes and workplaces. These span from Hawaii (HMSA) to Minnesota (Blue Cross and Blue Shield of Minnesota and OptumHealth), Pennsylvania (Rite Aid) and New York (HealthNow New York), among others.

As with any change, there are real risks involved. Even with its increasingly high-definition audiovisual capabilities, telemedicine does not allow for a hands-on exam. It thus requires physicians to exercise different clinical judgment on the care they render. Patients may abuse telemedicine to scout for physicians who more readily issue prescriptions (for regular or even controlled medications). Indeed, patients may abuse telemedicine as a whole by simply overusing it. After all, it is available at home right after dinner when there are no good shows on cable. Medical boards are rightfully concerned that state lines (which define physician licensure), or even national borders will perforate as patients look far and wide for their doctors. Lastly, since the Internet is open for all, it can become a goldmine for imposters, swindlers and downright poor-quality providers, to disseminate their wares.

But the challenges, real as they are, have been seen and conquered before. Amazon was blasted for taking the joy out of in-store book buying. Expedia eliminated the friendly agent from the travel agency down the street. Online banking and retail were feared to be leaky and insecure. Online grocery shopping did not allow the buyer to physically examine the produce and e-books turned the page on turning pages altogether. And yet they all prevailed somehow, and reached a point where they became an accepted part of our lives. This was done not by the persistence of the entrepreneurs, but by their adaptation. Not every product is sold on Amazon. Not every gourmet dinner is available to order in. Complex travel plans still end up with an agent and few people buy real estate entirely over the Internet.

Telemedicine is no different. It is right for a defined scope of medical care, but is not a replacement for the relationship between a patient and her doctor. Telemedicine needs to be portrayed clearly as such to remove ambiguity and unrealistic expectations. It needs the capability to validate that the people who use it are who they claim to be and that the providers in it are licensed, audited and held accountable to the quality of care they deliver by their state medical boards, as they are in their practices today. Prescriptions could be limited to known safe lists and, as with any other modern computer-based system, measures should be in place to constantly look for abusers, intruders and other forms of mayhem. All of the above is doable. We have done it before.

Telecommunication has changed almost every dimension of our lives within one generation. Telemedicine is its application in health care. It’s big, it’s powerful and it’s mostly asleep. With the current state of health care, isn’t it time we wake this elephant up?

The New Face of Medicine

Children’s Hospitals Today, Winter 2011

An interview on health care telepresence with Dr. Jason Knight, “the robot doctor” at Children’s Hospital of Orange County

Hoag Hospitals in both Newport Beach and Irvine, CA, have an unusual team member helping triage pediatric patients in the emergency departments: the RP-7 is a rolling robot that helps bring the telepresence of a far-off doctor into the room. Most often, the remote doctor behind the robot is Jason Knight, M.D., medical director of transport services at Children’s Hospital of Orange County. Knight is literally the face of this technology for many of the pediatric patients seen in both Hoag emergency departments. When the robot rolls into a room, the high-resolution display that is the “head” of the robot is usually a live feed of Knight wearing a welcoming smile.

Rationale for remote consulting

“Putting a robot at Hoag started as part of our support and commitment to the children of the nearby Newport Beach area,” Knight says. “The robot can move anywhere in the emergency department. I can use it to talk to patients, their families and emergency department physicians, and most importantly, I can look at the patient, look at the monitors, and check vital signs. I can even listen to the heart and breath sounds with a stethoscope attachment that plugs into the robot. All the data coming into my eyes and ears is something that I never would have had before this system.”

A few years ago, Hoag Hospital Newport Beach, which was primarily seeing adult patients, hired a new chief executive officer who made a business case to close the hospital’s low-census pediatric unit. The decision was made to work with CHOC, approximately 15 miles away, to have it transport and admit any pediatric patients in need of specialized services. As part of his roll with transport services, Knight was the physician leader responsible for putting a robot in the Hoag’s Newport Beach emergency department.

“Hoag created a special status for consulting doctors using the robot; there is now a separate certification for telemedicine privileges just for people like me. My only roll at Hoag is performing telemedicine consults,” Knight says. “On our end at CHOC, we trained all the intensivists and transport team on how to use the robot. A pediatric intensivist is available 24/7 to assist and consult on any pediatric patient that comes into the Hoag emergency department.”

Robot capabilities

The Remote Presence RP-7 robot, made by InTouch Health, can be remotely controlled by a joystick from anywhere with a compatible control station. There are approximately 200 RP-7 units in use at hospitals nationwide. Wheels allow the robots to move around on any flat surface, and a system of high precision video cameras, microphones and a stethoscope make it possible for doctors like Knight to examine patients, talk with families and consult ”in-person” with medical staff to decide on the best course of treatment.

“The clarity of the RP-7 system is fantastic. I have the ability to look 360-degrees and can even zoom in on any detail from the corner of a room and look closely at a patient’s respiratory pattern, examine their perfusion, watch the capillary refill time.  I can make it even better with still images if I need to. I can then display the images on the robot’s display and draw on the picture from my remote station to highlight details on X-rays, EKGs,” Knight says. “I can narrate and ‘telestrate’ anything that might help in planning treatment; it’s all highly reliable, and it’s all done in real time.”

Reactions to a robot doctor

The robot has been in place at Hoag Hospital Newport Beach for almost three years, and at Hoag Hospital Irvine since it opened on September 1, 2010, but it is still a novelty and reason for excitement for patients.

“They love it,” Knight says. “I have probably done more telemedicine consults than anyone in our hospital—4 to 6 per month on average. I have the ability to assess a patient, recommend interventions and outline a plan of care for the child. This gives families and caregivers incredible peace of mind. I have yet to have a family say anything negative about it. Usually, they are surprised, impressed and put at ease, knowing a pediatric-trained specialist was involved from the beginning.

“The most fun part of the system is when I get to follow up at CHOC with a patient who first met me through the robot at Hoag. The reaction I get the most is ‘hey, you’re the robot doctor!’” Knight says. “I get to explain that in reality, I’m a real doctor who is here caring for patients, but technology has made it possible for me to meet you, and for you to see my face on the robot, before you ever walk into CHOC.”

Next steps for telepresence

CHOC has a second RP-7 robot in action at the newly opened Hoag Hospital location in Irvine, CA, and Knight sees telepresence functionality growing radically in the next few years.

“My hope for the future is to have a portable RP transport unit that allows me to assess any patient being transported by the CHOC team,” Dr. Knight says. “I’m hopeful that in 2011, I will be able to visualize and start planning treatment for patients from the moment our transport team reaches them. The earlier we can provide pediatric-specific expertise to a patient, the better the care we can provide.”

Hopes for the future

With all the functionality available now, Knight is still looking at how the growth of telepresence technology will continue to change medicine.

“I would like to have the functionality for physicians to monitor patients from home. For instance, the cardiac surgeon operates all day and goes home at night. If he wants to see how his patients are doing in the ICU, he could log into a robot and do night rounds with the nurses before he goes to bed,” Knight says.

“On the other hand, we have patients who are chronic and have lots of medical problems and long term morbidities. Many are in-between; they can’t go home right now because they are too much work for their parents and because they can’t be adequately monitored, but they don’t need the full services of an ICU. If we could use telepresence like the RP-7 to check in daily, look at the patient’s vital signs, and talk with the family and home nurse, it could allow patients to spend more time at home. This would provide a huge cost savings over having a patient spend months in an acute care setting.

“I see some form of telepresence becoming standard practice for medicine in the next five years. And this is true whether we are talking about connecting to the home from the hospital or to the hospital from the home. The applications are endless in both directions.”

Interviewed by Tim Haynes, Assistant Director, Communications, NACHRI

The Digital Doctor Will See You Now

Online appointments offer speedier access to non-urgent medical care.

by: Alissa Ponchione | from: AARP The Magazine |

Like wireless Marcus Welbys, doctors will soon perform more house calls by computer or phone—good news if you’re sick of waiting for appointments. With many docs overbooked—wait times in metro areas such as Boston average 63 days, notes one new study—remote access can make your doctor less remote.

This year OptumHealth, part of UnitedHealth Group, plans to introduce a national system, the NowClinic, that offers 24-hour physician access. All you’ll need is a computer or phone and $45 for the ten-minute chat. Some retirement communities already use the Intel Health Guide, a remote monitoring system that records patients’ blood pressure and weight and lets off-site providers access data.

But telemedicine, though valuable, shouldn’t completely replace office visits, says Bill Russell, M.D., vice president of clinical informatics at Erickson Retirement Communities: “A good primary care physician should come to know their patient as a whole person, not just as an e-mail buddy.”

The Carematix Wellness System

The Carematix Solution

Carematix develops and markets state-of-the-art wellness monitoring systems. The Carematix Wellness System (CWS) is based on advanced, patent-pending, wireless and internet technologies that are seamlessly integrated into everyday health monitoring devices such as a blood-pressure monitor, weight scale, and glucose monitors.

The result is a very low-cost, extremely user-friendly end-to-end solution that allows physicians and nurses to monitor at-home patients with various health conditions and chronic diseases. (more…)

Carematix Customers

The Carematix Wellness System is an ideal solution for patients with hypertension (high blood pressure), diabetes, and preeclampsia. Regular monitoring of the basic wellness parameters provides significant benefits in helping to capture adverse events sooner, reduce hospital admissions, and improve the effectiveness of medications, hence, lowering patient care costs and improving the overall quality of care. Suitable users for such systems are disease management companies, health insurance companies, self-insured employers, medical device manufacturers and pharmaceutical firms. (more…)

The CWS provides easy monitoring of the basic wellness parameters via a wireless connection between the monitoring device and a hub (transceiver) located in the home.

The hub transmits the information to the Carematix internet server where the data is added to the patient’s chart.

Using a web-browser, the caregiver can track the patient’s data, graph the results, monitor trends, annotate variances, set alert criteria, and send reminders and receive alerts via e-mail or pager. (more…)

Telemedicine

Telemedicine is a rapidly developing application of clinical medicine where medical information is transferred via telephone, the Internet or other networks for the purpose of consulting, and sometimes remote medical procedures or examinations.

Telemedicine may be as simple as two health professionals discussing a case over the telephone, or as complex as using satellite technology and video-conferencing equipment to conduct a real-time consultation between medical specialists in two different countries. Telemedicine generally refers to the use of communications and information technologies for the delivery of clinical care.

Care at a distance (also called in absentia care), is an old practice which was often conducted via post; there has been a long and successful history of iin absentia health care, which – thanks to modern communication technology – has metamorphosed into what we know as modern telemedicine.

The terms e-health and telehealth are at times wrongly interchanged with telemedicine. Like the terms “medicine” and “health care”, telemedicine often refers only to the provision of clinical services while the term telehealth can refer to clinical and non-clinical services such as medical education, administration, and research. The term e-health is often, particularly in the UK and Europe, used as an umbrella term that includes telehealth, electronic medical records, and other components of health IT.

Telemedicine is practiced on the basis of two concepts: real time (synchronous) and store-and-forward and Home Health(asynchronous).

Real time telemedicine could be as simple as a telephone call or as complex as robotic surgery. It requires the presence of both parties at the same time and a communications link between them that allows a real-time interaction to take place. Video-conferencing equipment is one of the most common forms of technologies used in synchronous telemedicine. There are also peripheral devices which can be attached to computers or the video-conferencing equipment which can aid in an interactive examination. For instance, a tele-otoscope allows a remote physician to ’see’ inside a patient’s ear; a tele-stethoscope allows the consulting remote physician to hear the patient’s heartbeat. Medical specialties conducive to this kind of consultation include psychiatry, family practice, internal medicine, rehabilitation, cardiology, pediatrics, obstetrics, gynecology, neurology, speech-language pathology and pharmacy.

Store-and-forward telemedicine involves acquiring medical data (like medical images, biosignals etc) and then transmitting this data to a doctor or medical specialist at a convenient time for assessment offline. It does not require the presence of both parties at the same time. Dermatology (cf: teledermatology), radiology, and pathology are common specialties that are conducive to asynchronous telemedicine. A properly structured Medical Record preferably in electronic form should be a component of this transfer.

Home Health Telemedicine When a patient is in the hospital and he is placed under general observation after a surgery or other medical procedure, the hospital is usually losing a valuable bed and the patient would rather not be there as well. Home health allows the remote observation and care of a patient. Home health equipment consists of vital signs capture, video conferencing capabilities, and patient stats can be reviewed and alarms can be set from the hospital nurse’s station, depending on the specific home health device. Usually low bandwidth analog Plain Old Telephone System (POTS). Some newer systems do support higher bandwidth capabilities. Disease management, post-hospital care, assisted living, etc.

Telemedicine is most beneficial for populations living in isolated communities and remote regions and is currently being applied in virtually all medical domains. Specialties that use telemedicine often use a “tele-” prefix; for example, telemedicine as applied by radiologists is called Teleradiology. Similarly telemedicine as applied by cardiologists is termed as telecardiology, etc.

Telemedicine is also useful as a communication tool between a general practitioner and a specialist available at a remote location.

The first interactive Telemedicine system, operating over standard telephone lines, for remotely diagnosing and treating patients requiring cardiac resuscitation (defibrillation) was developed and marketed by MedPhone Corporation in 1989. A year latter the company introduced a mobile cellular version, the MDphone. Twelve hospitals in the U.S. served as receiving and treatment centers. (See: Telecommunications, Concepts, Development, and Management, Second Edition, pages 280-282, W. John Blyth, Glencoe/McCgraw-Hill Company,1990)

Monitoring a patient at home using known devices like blood pressure monitors and transferring the information to a caregiver is a fast growing emerging service. These remote monitoring solutions have a focus on current high morbidity chronic diseases and are mainly deployed for the First World. In developing countries a new way of practicing telemedicine is emerging better known as Primary Remote Diagnostic Visits whereby a doctor uses devices to remotely examine and treat a patient. Consultations monitors an already diagnosed chronic disease, AND has the promise to diagnosing and managing the diseases a patient will typically visit a general practitioner for.

Monday, January 31, 2011

Knee-replacement patients who undergo an Internet-based postoperative rehabilitation program experience similar — and sometimes better — outcomes than those who undergo traditional rehabilitation, according to a study published in the Journal of Bone and Joint Surgery, HealthLeaders Media reports.

Study Design

For the study, 65 patients who underwent total knee anthroplasty received six weeks of either Internet-based telerehabilitation or traditional outpatient rehabilitation services.

The telerehabilitation group participated in therapy sessions in a hospital room designed to replicate a typical home environment. A remote therapist provided guidance for the sessions, which involved self-applied therapy techniques and education on postoperative management of the affected knee.

Study Findings

After six weeks, researchers found that patients in the telerehabilitation group had:

  • Achieved better outcomes for reducing joint stiffness than patients undergoing conventional rehabilitation;
  • Completed an average of 2.2 exercise sessions daily, compared with an average of 1.7 exercise sessions daily among those in the control group;
  • Reported higher levels of satisfaction with their rehabilitation program than those in the control group; and
  • Showed significant improvement in specific functional areas designed to mimic daily activities.


Trevor Russell — study author and professor at the School of Health and Rehabilitation Science at the University of Queensland in Brisbane, Australia — said the study “provides evidence that traditional service delivery methods can be modified and adapted to the Internet environment and produce sound clinical outcomes” (HealthLeaders Media, 1/31).

Read more: http://www.ihealthbeat.org/articles/2011/1/31/study-shows-benefits-of-telerehabilitation-for-knee-surgery-patients.aspx#ixzz1E56Yk900

California Telehealth Network Gears Up for Launch

by David Gorn, iHealthBeat Contributing Reporter

These are heady days for Eric Brown. He’s the executive director for the California Telehealth Network, an organization partially funded by the Federal Communications Commission and run by the University of California-Davis that plans to use video feeds to eventually link medical specialists to more than 800 rural and underserved health care facilities across the state.

CTN recently announced that 25 medical facilities now are hooked up to a broadband network, bringing the futuristic vision of telehealth closer to reality in California.

“It’s a very exciting time,” Brown said, adding, “It’s good to be making progress. About 25 sites now have active circuits, and full functionality will come in the next week or two. We’re shooting for the first week of February.”

Having active circuits means the 25 sites can talk to each other, but not yet to consulting specialists at University of California medical centers. That will happen once CTN sets up computer equipment at the central facility to establish the firewall and enable a secure connection outside of the current network. Then, staff at the 25 sites will be able to consult via video chat in real time with specialist physicians from the eight UC medical centers, as well as a few private hospitals, such as Stanford University and the University of Southern California, Brown said.

“The vision is that the CTN eventually would be made available ubiquitously around the state — whether you’re urban or rural, nonprofit clinics or for-profit hospitals, you would have access to the CTN, to provide services or to receive services,” Brown said. He added, “Right now, our initial funding and focus is on these medically underserved areas to start with.”

More than 850 medical facilities in rural and underserved areas across California are eligible to be part of the telehealth network, Brown said. Most of those sites are rural, with about 30% to 35% of them in non-rural areas, and that’s roughly the breakdown of the 25 sites that are launching the project, he said. Places that qualify range from a clinic in San Francisco’s Chinatown to a hospital in Ukiah to a family health center in western Santa Barbara County.

Another Month, Another Project

In addition to going fully operational at the start of February, the CTN has two other initiatives it’s about to set into motion.

“CTN and UC-Davis recently received a broadband grant that’s going to kick off in the next 60 days,” Brown said. The idea of the project is to find “communities” of facilities that have started to use health IT and help them band together to create something new and innovative, he said.

“We’re looking for a collection of sites united by a common approach to using technology,” Brown said, adding, “We want to partner with those sites that are embracing technology and bringing technology more deeply into the community, and we want to see if we can accelerate that by providing broadband to these areas.”

For instance, he said, there are a number of federally qualified health centers, or FQHCs, that have school-based clinics in the community. “If we were able to set up a kiosk at these clinics, patients could see videos on lifestyle and nutrition there.” Or, he said, there could be a system where people go to a public library or community center to have their vital signs checked and then have that information sent along to their primary care physician through a secure network.

“Those are the kinds of concepts that these communities are being urged to put together,” Brown said.

The other project is more internal: setting up a business plan to determine where future efforts and resources will go. Brown said funding for a business plan consultant will be provided by the California HealthCare Foundation, which is represented on the CTN board of directors. CHCF publishes iHealthBeat.

“Obviously, there are so many things you could do,” Brown said. “How do you decide what to do first? And how do you ensure sustainability over the long run?”

Brown said a request for proposals for both projects will go out around the first week of February. The model community project probably will be chosen in February and is expected to be up and running by July, he said.

Next Steps for Telemedicine

Establishing a broadband connection for isolated or underserved communities is the culmination of a long effort, yet it also is just the start of the telemedicine project.

One criticism of the project is that there is no standard for transmission of electronic health records. Physicians using the telemedicine network are not yet able to transfer patient charts.

“We haven’t gotten to that point yet,” Brown said, adding, “That has to be an agreement between two sites doing a consultation on a patient. They’re left to their own to figure out the transmission of medical information securely.”

In a way, physicians do this now, by consulting with other health care providers on the phone. The video component of the CTN allows consulting physicians to see a patient’s symptoms and view any scans, and the complete health record is not always necessary, Brown said.

“It’s open platform,” he said, “so that’s one of our challenges. There certainly are a lot of vendors trying to solve that with health information exchange platforms.”

In some cases, just having the broadband connection could help sites find health record systems that are compatible with various other sites, and to pool information and buying power to get the best EHR system. “What the CTN can do is help facilitate a telemedicine session or teleconferencing system to share that information,” Brown said.

The “first focus is to just get the network launched,” Brown said. “Then we pivot to figure out what applications are in highest demand, and where do we want to expand the network.”

Expanding the Network

The goal of the CTN is to bring specialty care to areas of California that don’t have it.

To do that, the Center for Connected Health Policy started the Specialty Care Safety Net Initiative. The idea is to connect safety-net patients with physicians in six medical specialties, and over time, to evaluate which areas and which specialties have the greatest demands.

“That will be one of our early indicators [to see where to expand effort],” Brown said. “Our mission is to use broadband to efficiently utilize those specialty services. Again, that’s just in the early stages. But that’s the vision.”

Hooking up the wires is a great start, but Brown wants to go a few steps further to make sure participants get full use out of the system.

“We need to see how we can facilitate or broker services with those who need it,” he said.

With the expansion of health care coverage coming in 2014 as part of national health care reform, the demand for specialty services could rise, particularly in underserved areas, he said.

“My sense is, if you look where the specialists are located, it’s not always matched up with heaviest patient loads,” Brown said. “If you look at the long-term future, it is clear there will be more people entering the system, and specialty care will not keep pace with that.”

So the future is now, Brown said with a smile — but it’s also in the future.

“That’s the daunting challenge of this. There is so much still to be done,” he said.

“It’s a little scary at first, but it’s fun, too. You have to be prepared to learn as you go,” he said. “Because what we’re doing, a lot of these things haven’t been done before.”

When you look at innovations in medicine such as EHRs, Brown said, “it’s already starting to look different in medicine. Right now. It’s a very different environment than it was a few years ago, even. It’s not a 10-year window, it’s closer to two years, or five years,” he said, before the face of medicine changes dramatically.

“It’s already started, the technology is increasingly pervasive,” Brown said. “We want to make sure that the rural and the underserved aren’t left out of that. We want to make sure we find a way to include everybody.”

Read more: http://www.ihealthbeat.org/features/2011/california-telehealth-network-gears-up-for-launch.aspx#ixzz1E571XgPu

Obama Cites Importance of Health IT in State of the Union Address

During his State of the Union address Tuesday night, President Obama made several references to the importance of health IT, Healthcare IT News reports.

While citing progress the U.S. has made in using technology to reduce waste, Obama said, “Veterans can now download their electronic medical records with a click of the mouse.”

Obama also cited health IT when calling for an expansion of access to high-speed wireless networks. He said, “Within the next five years, we will make it possible for business to deploy the next generation of high-speed wireless coverage to 98% of all Americans” (Manos, Healthcare IT News, 1/25). He continued, “This isn’t about faster Internet or fewer dropped calls. … It’s about a firefighter who can download the design of a burning building onto a handled device; a student who can take classes with a digital textbook; or a patient who can have face-to-face video chats with her doctor” (Dolan, Mobihealthnews, 1/26).

Obama also stressed the importance of continuing to invest in IT innovation. He said, “Cutting the deficit by gutting our investments in innovation and education is like lightening an overloaded airplane by removing its engine. It may feel like you’re flying high at first, but it won’t take long before you feel the impact.”

Reaction

Justin Barnes — chair emeritus of the Healthcare Information and Management Systems Society’s Electronic Health Record Association and vice president of government affairs at Greenway Medical — said, “This is the eighth year in a row that health care IT has been a part or prominent part of the president’s State of the Union address.”

Barnes — who has been advising the White House and Congress on health IT since 2003 — said, “While the debate will certainly continue on exactly how we go about creating and implementing policy, it was very encouraging to hear the increased vigor supporting additional investments in innovation around biomedical research and information technology” (Healthcare IT News, 1/25).

Read more: http://www.ihealthbeat.org/articles/2011/1/26/obama-cites-importance-of-health-it-in-state-of-the-union-address.aspx#ixzz1E57SkgKV

American Telemedicine Association

Public Policy

ATA Federal Policy Priorities

Six Immediate Actions for President Obama’s Administration for Telehealth

– ATA has prepared the following issue briefs to discuss with the Administration:.)

Mandating Telemedicine as a Covered Service under Federal Health Benefit Plan

Medicare Coverage for Technology-Aided “Physician Services”

Improve Process for Adding Medicare Telemedicine Services

Telemedicine Priorities for the Center for Medicare and Medicaid Innovation

Administration’s FY2012 Legislative Proposals

Joint Federal Agency Coordination on Telemedicine

National health insurance reform, Patient Protection and Affordable Care Act, Public Law 111-148

Overview of telehealth provisions

Text of major telehealth sections:

Medicaid “health home” option for chronic care (section 2703)

Medicare “accountable care organization” demonstration (section 3022)

Medicare “Independence at Home” demonstration (section 3024)

Center for Medicare and Medicaid Innovation (section 3021)

National Health Reform Timeline and Telemedicine

ATA’s Federal Policy Priorities for 2011

Pending Telemedicine Bills in Congress

Summary of Telemedicine-Related Bills Currently in Congress (15 October 2009)

Policy Updates

ATA Submits CMS Code Requests for 2012 (31 December 2010) – ATA has submitted a request for several new telemedicine-related CPT codes to the Center for Medicare and Medicaid Services (CMS) for consideration in 2012. In addition to several specific code requests, ATA recommends that CMS facilitate, the the maximum extent of the law, the inclusion of Medicare services provided using telecommunications technology. Click here for a PDF version of ATA’s submitted requests.

GAO: FCC’s Poor Management Jeapordizes Rural Health Care Program (17 December 2010) – The U.S. Government Accountability Office (GAO) has released a highly critical report of the FCC’s management of the Rural Health Care Program. According to the report, FCC’s poor planning and communication during design and implementation has caused delays and difficulties for pilot program participants. GAO has issued several remedial recommendations. ATA had previously noted similar management problems in it’s own comments to the FCC.

ATA’s Comments on Accountable Care Organizations Provision in PPACA (3 December 2010) – ATA’s letter to CMS administrator, Dr. Donald Berwick, regarding the Accountable Care Organizations Provision in the Patient Protection and Affordable Care Act. For more information on Accountable Care Organizations, check out the ACO Page on ATAwiki.

CMS Announces Additions to Telehealth Coverage for 2011 (2 November 2010) – the Centers for Medicare and Medicaid Services (CMS) has finalized all of their proposed telehealth code additions that were originally published in June 2010. These changes will go into effect January 1, 2011.

FCC Issues Proposed Changes in $400 Million Rural Health Program: ATA Preparing Significant Comments on the Proposal (23 August 2010) – The Federal Communications Commission’s (FCC) has released a Notice of Proposed Rulemaking (NPRM) proposing reforms to the Universal Service, Rural Health Care Fund. The proposal was announced on August 9, 2010. The Rural Health Care Fund is capped at $400 million per year but utilization of the program has only been around 10 percent of the total. This is a significant development for many ATA members and the Association is in the process of developing comments to the FCC regarding its proposed changes. The ATA comments make a number of significant suggestions to alter the proposed rulemaking.

CMS Proposal on Credentialing and Privileging for Telehealth Providers by Medicare Hospitals (21 May 2010) – The Centers for Medicare and Medicaid Services (CMS) will propose new regulations on Wednesday May 26 in the Federal Register addressing the credentialing and privileging of physicians and practitioners providing telemedicine services. The proposed rule would streamline the process that Medicare-participating hospitals partnering to deliver telemedicine services use to credential and grant privileges to telemedicine physicians. A hospital that provides telemedicine services to its patients via an agreement with a “distant-site” hospital would be allowed to rely upon information furnished by the distant-site hospital (often a larger medical center) in making credentialing and privileging decisions for the distant-site hospital’s physicians and practitioners who provide the telemedicine services. The new flexibility under the proposed rule would reduce the burden and duplicative nature of the traditional credentialing and privileging process for Medicare-participating hospitals and CAHs that are engaged in telemedicine agreements, while still assuring accountability to the process. CMS will accept comments on the proposal through July 26

Administration’s Proposed Broadband Plan Released (16 March 2010) – The Federal Communications Commission released its proposed broadband plan. “Connecting America: The National Broadband Plan” was developed after extensive public hearings and many meetings with multiple stakeholders. The American Telemedicine Association provided numerous suggestions for the plan and members of ATA testified before the Commission. The plan includes an extensive section on healthcare and includes a number of specific policy recommendations to lift existing barriers to the deployment of telemedicine.

ATA Video Presentation – Federal Support for Telemedicine (February 2010) (Passcode: 35465) – One of the most frequent questions to ATA involves federal support for telemedicine in the United States. To shed light on this issue, ATA has produced a short video (16 minutes), with general information on government funding, reimbursement and participation in telemedicine.

ATA Submits Request for Additional Medicare Reimbursement (December 2009) – ATA formally requested several CPT codes to be added to the list of medical services that can receive reimbursement under Medicare. The request, submitted to the Center for Medicare and Medicaid Services (CMS), asked for approval of codes related to providing services to patients residing in telemental health and skilled nursing facilities. In addition, we recommended changes to improve the annual code request process. The agency will consider the request and include their response in their annual physician fee schedule announcement in late summer of 2010.

Medicare Telehealth Amendment by Senator Tom Udall (9 December 2009) — Senate amendment 3136 focuses on high impact, low cost strategic advances and high priorities for telemedicine. Most importantly, the amendment would: 1) Direct CMS to improve credentialing and privileging of physicians and other providers and in the mean time to cease enforcing its outmoded and excessively burdensome requirements; 2) For the first time provide video conferencing coverage for the 34 million Medicare beneficiaries who live in metropolitan counties; 3) For the first time get ?store and forward? services outside of Alaska and Hawaii demo sites. Click here for text of amendment. Click here for Udall summary.

RUS and NTIA Request Info to Improve BIP and BTOP (10 November 2009) — Agriculture’s Rural Utilities Service and Commerce’s National Telecommunications and Information Administration issued a joint request for information seeking comment on further implementation of the Broadband Initiatives Program and the Broadband Technology Opportunities Program. The input is intended to inform the second and final round of ARRA funding in early 2010. Comments must be received by November 30. Click here for the notice.

FCC Seeks Comment on Health Care Delivery for National Broadband Plan (12 November 2009) – On or before December 4, the Federal Communications Commission is seeking comments on detailed aspects for purpose of its National Broadband Plan, due mid-February. Specific areas of inquiry are IT infrastructure to support healthcare delivery, connectivity requirements, value capture and use cases, health IT use drivers and barriers, data security, and universal service rural health care support and pilot program. Click here for FCC notice. Click here for ATA’s Comments. Click here for comments from Internet2.

Comments on Telemedicine and Emergency Response – FCC Broadband Field Hearing (12 November 2009) Comments delivered by Jon Linkous, CEO of the American Telemedicine Association.

Rural TECH (Telemedicine Enhancing Community Health) Act Introduced (5 November 2009) – Sen. Tom Udall (D-NM) introduced a bill to establish telehealth pilot projects, expand access to stroke telehealth services under the Medicare program, improve access to “store-and-forward” telehealth services in facilities of the Indian Health Service and Federally qualified health centers, reimburse facilities of the Indian Health Service as originating sites, establish regulations to consider credentialing and privileging standards for originating sites with respect to receiving telehealth services, and for other purposes. This will be the basis of the Senator’s effort to include this package in the national health reform bill. Click here for ATA’s summary and Udall’s introductory statement. Click here for the bill text.

CMS Finalizes 2010 Medicare Part B Fee Schedule for Physicians and Others (30 October 2009) – For telehealth purposes, there are no significant changes from the proposed rule. The fee for telehealth originating sites will be $24 in 2010, up from $23. The final rule will be published in the Federal Register on 25 November. Click here for CMS final rule.

» CMS Proposes 2010 Medicare Physician Fee Schedule(1 July 2009) – This proposed rule would address proposed changes to Medicare Part B payment policy, including telehealth services; refinements to resource-based work, practice expense and malpractice relative value units; geographic practice cost indices; several coding issues; physician fee schedule update for 2010 and many other aspects. Click here for ATA comments

House Leadership Introduces National Health Reform Bill (29 October 2009) – For ATA summary of telehealth provisions, click here. For text of H.R. 3962, click here. For section-by-section analysis, click here.

FCC Workshop on Broadband for Health (15 September 2009) – Telehealth and other health issues important for the Federal Communications Commission’s pending National Broadband Plan were aired today. Three of ATA’s leadership presented: Karen Rheuban, Dale Alverson and Nina Antoniotti. Also of note, is the presentation of President Obama’s Chief Technology Officer, Aneesh Chopra. Click here for FCC’s archived 3 hour webcast (in Real Audio) and click here for ATA’s timed index of the presenters.

ATA’s Comments to the FCC on Fostering Innovation and Investment in the Wireless Communication Market (27 August 2009) – The Federal Communications Commission filed a Notice of Inquiry (NOI) seeking to understand better the factors that encourage innovation and investment in wireless and to identify concrete steps the Commission can take to support and encourage further innovation and investment in this area. Click here for ATA comments.

ATA Comments to FCC on MBAN (6 August 2009) – The Federal Communications Commission seeks comment on allocating spectrum and establishing service and technical rules for the operation of medical body area network (or MBAN) systems using body sensor devices. MBAN systems would provide a flexible platform for the wireless networking of multiple body sensors used for monitoring a patient’s physiological data, primarily in health care facilities. Click here for ATA comments.

Broadband Funding Available (1 July 2009) – A $4 billion funding opportunity for broadband was announced by the Rural Utilities Service (RUS), Department of Agriculture, and National Telecommunications and Information Administration (NTIA), Department of Commerce. RUS is establishing the Broadband Initiatives Program (BIP) which may extend loans, grants, and loan/grant combinations to facilitate broadband deployment in rural areas. NTIA is establishing the Broadband Technology Opportunities Program (BTOP) which makes available grants for deploying broadband infrastructure in unserved and underserved areas, enhancing broadband capacity at public computer centers, and promoting sustainable broadband adoption projects. The application period is now closed.

“Meaningful use” Draft Recommendations (16 June 2009) — Today the federal HIT Policy Committee released draft recommendations for the term “meaningful use.” The American Recovery and Reinvestment Act provides for Medicare and Medicaid incentive payments for eligible providers who demonstrate “meaningful use” of a certified EHR. HHS expects to issue the proposed rule in late 2009, which will be followed by another comment period. Click here for the HHS web page with links to three related documents and comment instructions. Click here for ATA comments.

ATA’s Comments on the FCC “National Broadband Plan For Our Future” (8 June 2009) The Federal Communications Commission filed a Notice of Inquiry (NOI) regarding the development of a National Broadband Plan, due February 17, 2010. ATA commented on some of the larger issues as well as issues directly pertinent to our field of expertise. Click here for ATA comments.

ONC Explains Regional Extension Centers (28 May 2009) — The HHS Office of the National Coordinator for Health Information Technology published a notice that outlines its thinking on establishment of regional health I.T. extension centers. Click here to view ATA’s comments.

CMS Proposes Medicare Rulemaking Affecting SNFs As Telehealth Originators (12 May 2009) – Last year Congress authorized Medicare skilled nursing facilities to be originating sites for telehealth services and thus receive a facility fee for such services. Today the Centers for Medicare and Medicaid Services published implementing information as part of the proposed rules for prospective payment and consolidating billing for federal fiscal year 2010. Click here for ATA comments.

Baucus, Grassley Release Policy Options For Expanding Health Care Coverage (11 May 2009) – Senate Finance Committee Chairman Max Baucus (D-MT) and Ranking Member Chuck Grassley (R-IA) released policy options for expanding health care coverage to the 46 million Americans who are currently uninsured. The options are the second of three papers that Members will discuss before a Finance Committee mark-up of comprehensive health reform legislation in June. Click here for ATA comments.

Update on H.R. 2068 (5 May 2009) – H.R. 2068, the Medicare Telehealth Enhancement Act would expand the Medicare coverage in several important ways, notably it would: 1) Remove Medicare’s rural restriction so that people in urban and suburban areas would be covered; 2) Expand store-and-forward use to many HHS-funded sites; 3) Add kidney dialysis facilities as originating sites; 4) Allow use of telemedicine for all Medicare-covered providers; 5) Assure a telemedicine practitioner credentialed by a hospital in compliance with the Joint Commission standards shall be considered in compliance with Medicare condition of participation and reimbursement credentialing requirements for telemedicine services; 6) Provide for the use of telehealth in home care and remote monitoring for chronic conditions, and; 7) Re-authorizes the highly successful telehealth grant program administered by HHS and authorizes an additional grant program to develop new networks. ATA has drafted a letter for members to use to urge their Representative to co-sponsor this important piece of legistlation.

Baucus, Grassley Release Policy Options For Transforming The Health Care Delivery System (28 April 2009) – Senate Finance Committee Chairman Max Baucus (D-MT) and Ranking Member Chuck Grassley (R-IA) released policy options for reducing costs and improving quality in the health care delivery system. The options are the first of three papers that Members will discuss before a Finance Committee mark-up of comprehensive health reform legislation in June. Public comments are due May 15. Click here to view ATA’s Comments.

ATA’s Recommendations for Implementation of Stimulus Package (27 January 2009) – The American Telemedicine Association issued a set of specific recommendations for implementing federal stimulus funds identified in the proposed American Recovery and Reinvestment Act of 2009. In its recommendations, ATA pointed out that federal spending for telemedicine allocated through the supplemental bill can be spent quickly and the resulting benefits, including increased investments, expanded access to healthcare, improved quality and reduced cost of overall health expenditures, can start to be realized within one year. ATA is asking Congress and the Administration to direct funds already contained in the proposed spending measure in seven specific areas: improving Telemedicine Infrastructure, expanding Telecommunications and Broadband Infrastructure, coordination of Federal Telemedicine and Telecommunication Spending, Expanding U.S. Exports of Health Services, Using Telemedicine for Disaster Response, Development of Guidelines and Standards and, integrating Telemedicine in Federally Managed Health Programs. The stimulus bill does not address several important issues for telemedicine such as Medicare reimbursement and the FCC Rural Health Program. These issues will be addressed in discussions of healthcare reform and telecommunications reform which will take place later this year.

ATA Submits Request for Additional Medicare Reimbursement (December 2008) – ATA has formally requested several CPT codes to be added to the list of medical services that can receive reimbursement under Medicare. The request, submitted to the Center for Medicare and Medicaid Services (CMS), asked for approval of codes related to providing services to patients residing in skilled nursing facilities. The agency will consider the request and include their response in their annual physician fee schedule announcement in late summer of this year.

CMS Final Rule Released (3 November 2008) – The U.S. Centers for Medicare and Medicaid Management (CMS) just released its final rule under the annual physician fee schedule policies for 2009. In the rule, CMS largely affirmed decisions described in the preliminary announcement earlier this year. However, in response to a request and inquiry from ATA, the agency announced that it will start reimbursing approved telehealth services for skilled nursing facilities starting in 2009. Further, although no immediate approval was given, CMS agreed to evaluate the use of a number of additional codes related to skilled nursing facilities in its review for 2010. ATA outlined these codes in our request as: initial nursing facility care (as described by HCPCS codes 99304 through 99306); subsequent nursing facility care (HCPCS codes 99307 through 99310); nursing facility discharge services (HCPCS codes 99315 and 99316); and other nursing facility services (as described by HCPCS code 99318). A pdf file of the final rule is available here.

Final Victory for Telemedicine Reimbursement (16 July 2008) – Telemedicine achieved final victory in its quest to add new originating sites for Medicare reimbursement on July 16 when Congress overrode President Bush’s veto of H.R. 6331. Under this new law, as of January 1, 2009, skilled nursing facilities, in-hospital dialysis centers and community mental health centers will be originating sites for Medicare reimbursement. Read More >>

Emergency Communications Report Released (February 2008) – A federal government report, just released by Congress, makes a series of recommendations about improving communications between emergency responders and health facilities. Included in the recommendations are a number of suggestions for the increased use of telemedicine and improved linkages between public health, medicine and emergency responders. The report was prepared by a bipartisan Joint Advisory Committee, established by Congress as a result of the 9-11 Commission. It was delivered last week to leaders of the House and Senate for their consideration. ATA Executive Director Jonathan Linkous served as chair of the Public Health Group within the Committee. Several other ATA members also served on the Committee. A news release from the House Commerce Committee is available here; the full report is available here.

FCC Approves ATA’s Request to Extend “Grandfathered” Sites (February 2008) – The Federal Communications Commission (FCC) approved a petition filed by the American Telemedicine Association and have agreed to extend, for three years, eligibility for certain health care providers receiving financial support under the Rural Health Program who lost their eligibility when the FCC changed its definition of “rural.” (Details of the order are available here.) ATA filed a “Petition for Reconsideration” in March 2005, right after the FCC changed its definition of rural. The changed definition resulted in approximately 200 sites losing their eligibility under the program. ATA asked for a permanent exemption for the sites.

Telemedicine Patent Issue Update – ATA Calls for Telemedicine Patent to be Re-Examined (February 2008) – ATA sent a letter to the U.S. Patent Office regarding the controversy stemming from the issuance of a patent on a hub and spoke telemedicine method. In the letter, ATA Executive Director Jonathan D. Linkous says ATA believes the patent has been issued in error and calls on the Patent Office to re-examine the patent in light of the many examples of telemedicine networks in operation prior to the date of the patent. The Canadian Intellectual Property Office decided in February to pull its issuance of a similar patent in Canada and is re-examining the issue. Linkous says that ATA was stunned the patent was issued and expresses concern that the patent may have a chilling effect on the practice of telemedicine.

Public Policy Links

Congressional Information – The Library of Congress provides you with searchable information about the U.S. Congress and the legislative process. Search bills by topic, bill number, or title. Search through and read the text of the Congressional Record for the 101st through the 109th Congresses. Search and find committee reports by topic or committee name.

www.recovery.govU.S. government website that explains where money from the American Recovery and Reinvestment Act is going. There will be different ways to search for information. The money is being distributed by Federal agencies, and soon you’ll be able to see where it’s going — to which states, to which congressional districts, even to which Federal contractors.

www.grants.gov – source to find and apply for federal government grants

www.regulations.gov – source to find and comment on proposed federal government regulations

Medicare Telehealth

Medicaid Telemedicine and Telehealth

HHS Office for the Advancement of Telehealth

Medicare Payment Advisory Commission

Government Accountability Office

Center for Telehealth and eHealth Law’s National Telehealth Resource Center

Federal Telemedicine Update – An online newsletter by Carolyn Bloch

American Telemedicine Association
Telemedicine/Telehealth Terminology

The following is a list of terms and definitions that are commonly used in telemedicine/telehealth. The list was assembled for the purpose of encouraging consistency in employing these terms in ATA related documents and resource materials. The list is not all-inclusive and may be augmented by for specialty areas as deemed appropriate by ATA member groups.

Application Service Provider (ASP): An ASP hosts a variety of applications on a central server. For a fee, customers can access the applications that interest them over secure Internet connections or a private network. This means that they do not need to purchase, install and maintain the software themselves; instead they rent the applications they need from their ASP. Even new releases, such as software upgrades, are generally included in the price.

Asynchronous: This term is sometimes used to describe store and forward transmission of medical images or information because the transmission typically occurs in one direction in time. This is the opposite of synchronous (see below).

Authentication: A method of verifying the identity of a person sending or receiving information using passwords, keys and other automated identifiers.

Bandwidth: A measure of the information carrying capacity of a communications channel; a practical limit to the size, cost, and capability of a telemedicine service.

Bluetooth Wireless: Bluetooth is an industrial specification for wireless personal area networks (PANs). Bluetooth provides a way to connect and exchange information between devices such as mobile phones, laptops, PCs, printers, digital cameras and video game consoles over a secure, globally unlicensed shortrange radio frequency. The Bluetooth specifications are developed and licensed by the Bluetooth Special Interest Group.

Broadband: Communications (e.g., broadcast television, microwave, and satellite) capable of carrying a wide range of frequencies; refers to transmission of signals in a frequency-modulated fashion, over a segment of the total bandwidth available, thereby permitting simultaneous transmission of several messages.

Clinical Information System: Relating exclusively to the information regarding the care of a patient, rather than administrative data, this hospital-based information system is designed to collect and organize data.

CODEC: Acronym for coder-decoder. This is the videoconferencing device (e.g., Polycom, Tandberg, Sony, Panasonic, etc) that converts analog video and audio signals to digital video and audio code and vice versa. CODECs typically compress the digital code to conserve bandwidth on a telecommunications path.

Compressed video: Video images that have been processed to reduce the amount of bandwidth needed to capture the necessary information so that the information can be sent over a telephone network.

Computer-based Patient Record (CPR): An electronic form of individual patient information that is designed to provide access to complete and accurate patient data.

Data Compression: A method to reduce the volume of data using encoding to reduce image processing, transmission times, bandwidth requirements, and storage space requirements. Some compression techniques result in the loss of some information, which may or may not be clinically important.

Diagnostic Equipment (Scopes, Cameras & Other Peripheral Devices): A hardware device not part of the central computer (e.g. digitizers, stethoscope, or camera) that can provide medical data input to or accept output from the computer.

Digital Camera (still images): A digital camera is typically used to take still images of a patient. General uses for this type of camera include dermatology and wound care. This camera produces images that can be downloaded to a PC and sent to a provider/consultant over a network.

Digital Imaging and Communication in Medicine (DICOM): A standard for communications among medical imaging devices; a set of protocols describing how images are identified and formatted that is vendor-independent and developed by the American College of Radiology and the National Electronic Manufacturers Association.

Disease Management: A continuous coordinated health care process that seeks to manage and improve the health status of a carefully defined patient population over the entire course of a disease (e.g., CHF, DM) The patient populations targeted are high-risk, high-cost patients with chronic conditions that depend on appropriate care for proper maintenance.

Distance Learning: The incorporation of video and audio technologies, allowing students to “attend” classes and training sessions that are being presented at a remote location. Distance learning systems are usually interactive and are a tool in the delivery of training and education to widely dispersed students, or in instances in which the instructor cannot travel to the student’s site.

Distant Site: The distant site is defined as the telehealth site where the provider/specialist is seeing the patient at a distance or consulting with a patient’s provider. (CMS) Others common names for this term include – hub site, specialty site, provider/physician site and referral site. The site may also be referred to as the consulting site.

Document Camera: A camera that can display written or typed information (e.g., lab results), photographs, graphics (e.g., ECG strips) and in some cases x-rays.

Electronic Data Interchange (EDI): The sending and receiving of data directly between trading partners without paper or human intervention.

Electronic Patient Record: An electronic form of individual patient information that is designed to provide access to complete and accurate patient data, alerts, reminders, clinical decision support systems, links to medical knowledge, and other aids.

Encryption: A system of encoding data on a Web page or e-mail where the information can only be retrieved and decoded by the person or computer system authorized to access it.

Firewall: Computer hardware and software that block unauthorized communications between an institution’s computer network and external networks.

Full-motion Video: This describes a standard video signal that allows video to be shown at the distant end in smooth, uninterrupted images.

Guideline: A statement of policy or procedures by which to determine a course of action, or give guidance for setting standards (Loane & Wootton, 2002).

H.320: This is the technical standard for videoconferencing compression standards that allow different equipment to interoperate via T1 or ISDN connections.

H.323: This is the technical standard for videoconferencing compression standards that allow different equipment to interoperate via the Internet Protocol (see below).

H.324: This is the technical standard for videoconferencing compression standards that allow different equipment to interoperate via Plain Old Telephone Service (POTS).

Health Level-7 Data Communications Protocol (HL-7): This communication standard guides the transmission of health-related information. HL7 allows the integration of various applications, such as bedside terminals, radiological imaging stations, hospital census, order entries, and patient accounting, into one system.

HIPAA: Acronym for Health Information Portability Act.

Home Health Care & Remote Monitoring Systems: Home health care is care provided to individuals and families in their place of residence for promoting, maintaining, or restoring health; or for minimizing the effects of disability and illness, including terminal illness. In the Medicare Current Beneficiary Survey and Medicare claims and enrollment data, home health care refers to home visits by professionals including nurses, physicians, social workers, therapists, and home health aides. Using remote monitoring and interactive devices allows the patient to send in vital signs on a regular basis to a provider without the need for travel.

Informatics: The use of computer science and information technologies to the management and processing of data, information and knowledge.

Integrated Services Digital Network (ISDN): This is a common dial-up transmission path for videoconferencing. Since ISDN services are used on demand by dialing another ISDN based device, per minute charges accumulate at some contracted rate and then are billed to the site placing the call. This service is analogous to using the dialing features associated with a long distance telephone call. The initiator of the call will pay the bill. ISDN permits connections up to 128Kbps.

Interactive Video/Television: This is analogous with video conferencing technologies that allow for two-way, synchronous, interactive video and audio signals for the purpose of delivering telehealth, telemedicine or distant education services. It is often referred to by the acronyms – ITV, IATV or VTC (video teleconference).

Internet Protocol: The Internet Protocol (IP) is the protocol by which data is sent from one computer to another on the Internet. Each computer on the Internet has at least one address that uniquely identifies it from all other computers on the Internet. IP is a connectionless protocol, which means that there is no established connection between the end points that are communicating. The IP address of a videoconferencing system is its phone number.

Interoperability: Interoperability refers to the ability of two of more systems* to interact with one another and exchange information in order to achieve predictable results (*refers to more than technical systems) (Bergman, Ulmer and Sargious, 2001). There are three types of interoperability: human/operational; clinical; and technical (Canadian Society for Telehealth, 2001). Interoperability refers to the ability of two or more systems (computers, communication devices, networks, software, and other information technology components) to interact with one another and exchange data according to a prescribed method in order to achieve predictable results (ISO ITC-215).

ISDN Basic Rate Interface (BRI): This is an ISDN interface that provides 128k of bandwidth for videoconferencing or simultaneous voice and data services. Multiple BRI lines can be linked together using a multiplexer (see below) to achieve higher bandwidth levels. For instance, a popular choice among telehealth networks is to combine 3 BRI lines to provide 384k of bandwidth for video-conferencing. It should be noted that BRI services are not available in some rural locations. One should check with their telecommunications providers on the availability of BRI service before ordering videoconferencing equipment that uses this type of service.

ISDN Primary Rate Interface (PRI): This is an ISDN interface standard that operates using 23, 64k channels and one 64k data channel. With the proper multiplexing equipment the ISDN PRI channels can be selected by the user for a video call. For instance if the user wants to have a videoconference at 384k of bandwidth then they can instruct the multiplexer to use channels 1 through 6 (6 x 64k = 384k). This is important because the user typically pays charges based on the number of 64k channels used during a videoconference. The fewer channels used to obtain a quality video signal the less expensive the call.

JCAHO: Acronym for Joint Commission on Accreditation of Healthcare Organizations.

Lossless: A format of data compression, typically of an order of less than 2:1, in which none of the original data information is lost when the image is reproduced.

Lossy: A process of data compression at a relatively high ratio, which leads to some permanent loss of information upon reconstruction.

Medical/ Nursing Call Center: A call center is a centralized office that answers incoming telephone calls from patients. Such an office may also respond to letters, faxes, e-mails and similar written correspondence. Usually staffed by nurses, call centers provide basic health information and instructions to callers but do not provide an official diagnosis of conditions or prescribe medicine. Call centers act as an initial triage point for patients.

Mobile Telehealth: The provision of health care services with the assistance of a van, trailer, or other mobile unit in which the health care provider might provide patient services at a distance from a normal medical facility. Services may also be provided through mobile technologies that allow a mobile vehicle equipped with medical technologies to attach to an existing health care facility, such as mobile CT, MRI, or TeleDentistry.

Multiplexer (MUX): A device that combines multiple inputs (ISDN PRI channels or ISDN BRI lines) into an aggregate signal to be transported via a single transmission path.

Multi-point Control Unit (MCU): A device that can link multiple videoconferencing sites into a single videoconference. An MCU is also often referred to as a “bridge”.

Multi-point Teleconferencing: Interactive electronic communication between multiple users at two or more sites which facilitates voice, video, and/or data transmission systems: audio, graphics, computer and video systems. Multi-point teleconferencing requires a MCU or bridging device to link multiple sites into a single videoconference.

Network Integrators: Organizations specializing in the development of software and related services that allows devices and systems to share data and communicate to one another.

Originating Site: The orginating site is where the patient and/or the patient’s physician is located during the telehealth encounter or consult (CMS). Other common names for this term include – spoke site, patient site, remote site, and rural site.

Patient Exam Camera (video): This is the camera typically used to examine the general condition of the patient. Types of cameras include those that may be embedded with set-top videoconferencing units, handheld video cameras, gooseneck cameras, camcorders, etc. The camera may be analog or digital depending upon the connection to the videoconferencing unit.

Peripheral Devices: Any device that is attached to a computer externally, i.e. Scanners, mouse pointers, printers, keyboards; and clinical monitors such as pulse oximeters, weight scales, are all examples of this.

Pharmacy Solutions: The use of electronic information and communication technology to provide and support comprehensive pharmacy services when distance separates the participants.

POTS: Acronym for Plain Old Telephone Service.

Presenter (Patient Presenter): Telehealth encounters require the distant provider to perform an exam of a patient from many miles away. In order to accomplish that task an individual with a clinical background (e.g., LPN, RN, etc) trained in the use of the equipment must be available at the originating site to “present” the patient, manage the cameras and perform any “hands-on” activities to successfully complete the exam. For example, a neurological diagnostic exam usually requires a nurse capable of testing a patient’s reflexes and other manipulative activities. It should be noted that in certain cases, such as interview based clinical consultations such as Telemental Health or Nutrition Services, that a licensed practitioner such as an RN or LPN, might not be necessary, and a non-licensed provider such as support staff, could provide telepresenting functions.

RHIO: Regional Health Information Organization (RHIO) and Health Information Exchange (HIE) are often used interchangeably. RHIO is a group of organizations with a business stake in improving the quality, safety, and efficiency of healthcare delivery. RHIOs are the building blocks of the proposed National Health Information Network (NHIN) initiative at the Office of the National Coordinator for Health Information Technology (ONCHIT).

Router: This device provides an interface between two networks or connects sub-networks within a single organization. It routes network traffic between multiple locations and it can find the best route between any two sites. For example, PCs or H.323 videoconferencing devices tell the routers where the destination device is located and the routers find the best way to get the information to that distant point.

Standard: A statement established by consensus or authority, that provides a benchmark for measuring quality, that is aimed at achieving optimal results (NIFTE Research Consortium, 2003).

Store and Forward (S&F): S&F is a type of telehealth encounter or consult that uses still digital images of a patient for the purpose of rendering a medical opinion or diagnosis. Common types of S&F services include radiology, pathology, dermatology and wound care. Store and forward also includes the asynchronous transmission of clinical data, such as blood glucose levels and electrocardiogram (ECG) measurements, from one site (e.g., patient’s home) to another site (e.g., home health agency, hospital, clinic).

Switch: A switch in the videoconferencing world is an electrical device that selects the path of the video transmission. It may be thought of as an intelligent hub (see hub above) because it can be programmed to direct traffic on specific ports to specific destinations. Hub ports feed the same information to each device.

Synchronous: This term is sometimes used to describe interactive video connections because the transmission of information in both directions is occurring at exactly the same period.

System/Network Integration: The use of software that allows devices and systems to share data and communicate to one another.

T1/DS1: A digital carrier or type of telephone line service offering high-speed data, voice, or compressed video access in two directions, with a transmission rate of 1.544 Mbps.

T3/DS3: A carrier of 45 Mbps.

TCP/IP (Transmission Control Protocol/Internet Protocol): The underlying communications rules and protocols that allow computers to interact with each other and exchange data on the Internet.

Telecommunications Providers: An entity licensed by the government (the Federal Communications Commission in the U.S.) to provide telecommunications services to individuals or institutions.

Teleconferencing: Interactive electronic communication between multiple users at two or more sites which facilitates voice, video, and/or data transmission systems: audio, graphics, computer and video systems.

Telehealth and Telemedicine: Telemedicine and telehealth both describe the use of medical information exchanged from one site to another via electronic communications to improve patients’ health status. Although evolving, telemedicine is sometimes associated with direct patient clinical services and telehealth is sometimes associated with a broader definition of remote healthcare services.

Telematics: The use of information processing based on a computer in telecommunications, and the use of telecommunications to permit computers to transfer programs and data to one another.

Telementoring: The use of audio, video, and other telecommunications and electronic information processing technologies to provide individual guidance or direction. An example of this help may involve a consultant aiding a distant clinician in a new medical procedure.

Telemonitoring: The process of using audio, video, and other telecommunications and electronic information processing technologies to monitor the health status of a patience from a distance.

Telepresence: The method of using robotic and other instruments that permit a clinician to perform a procedure at a remote location by manipulating devices and receiving feedback or sensory information that contributes to a sense of being present at the remote site and allows a satisfactory degree of technical achievement. For example, this term could be applied to a surgeon using lasers or dental hand pieces and receiving pressure similar to that created by touching a patient so that it seems as though s/he is actually present, permitting a satisfactory degree of dexterity.

Teleradiology and Picture Archiving and Communications Systems (PACs): The electronic transmission of radiological images, such as x-rays, CTs, and MRIs, for the purposes of interpretation and/or consultation. Digital images are transmitted over a distance using standard telephone lines, satellite connections, or local area networks (LANs). Teleradiology also is beginning to include the process of interfacing with the hospital information systems/radiology information systems (HIS/RIS) in the transport of digital images. PACs provide centralized storage and access to medical images over information systems.

Ultrasound: A device that uses high-frequency sound waves to examine structures inside the body. It can rapidly detect tumors and other abnormalities, often right in the physician’s office.

Universal Service Administrative Company (USAC): The Universal Service Administrative Company administers the Universal Service Fund (USF), which provides communities across the country with affordable telecommunication services. The Rural Health Care Division (RHCD) of USAC manages the telecommunications discount program for health care.

Videoconferencing Systems: Equipment and software that provide real-time, generally two way transmission of digitized video images between multiple locations; uses telecommunications to bring people at physically remote locations together for meetings. Each individual location in a videoconferencing system requires a room equipped to send and receive video.

Videoconferencing: Real-time, generally two way transmission of digitized video images between multiple locations; uses telecommunications to bring people at physically remote locations together for meetings. Each individual location in a videoconferencing system requires a room equipped to send and receive video.

WiFi: Originally licensed by the Wi-Fi Alliance to describe the underlying technology of wireless local area networks (WLAN) based on the IEEE 802.11 specifications. It was developed to be used for mobile computing devices, such as laptops, in LANs, but is now increasingly used for more services, including Internet and VoIP phone access, gaming, and basic connectivity of consumer electronics such as televisions and DVD players, or digital cameras. (Wikipedia)