Telemedicine Technical Assistance Documents A Guide to Getting Started in Telemedicine Joseph Tracy, MS University of Missouri – School of Medicine Editor Foreword by Dena Puskin, ScD Office for the Advancement of Telehealth © Copyright 2004 Contents Acknowledgements ...................................................................................................... ii Foreword....................................................................................................................... iii Chapters: 1. Introduction ..................................................................................................... 1 2. First Steps in Creating a Successful Telehealth Program .......................... 6 3. Cardiology ..................................................................................................... 23 4. Dermatology ..................................................................................................51 5. Disease Management .................................................................................... 85 6. Electronic Medical Records for Rural Health Systems ............................ 108 7. HIV/AIDS ...................................................................................................... 134 8. Home Care ................................................................................................... 151 9. Mental Health .............................................................................................. 188 10. Pharmacy ..................................................................................................... 206 11. Rehabilitation .............................................................................................. 241 12. School-based Services ............................................................................... 267 13. Telehealth Technology ............................................................................... 314 14. Trauma and Emergency Care .................................................................... 343 Appendicies A. Telehealth and Telecommunication Definitions ......................................... 377 B. About the Authors – Biographies ................................................................ 384 i Acknowledgements The primary and contributing authors of this work would like to gratefully acknowledge the federal Office for the Advancement of Telehealth, Health Resources and Services Administration, U.S. Department of Health and Human Services for funding this work. This work was conducted under the following grants numbers: 6H2A TM 00056-01-00 Marshfield Medical Research and Education Foundation 4H2A TH 00051-07-07 Curators of the University of Missouri 6D1B TM 00025-02-01 Susquehanna Health System 4D1B TH 00646-01-04 University of Virginia 6H2A TM 00235-06-01 University of Tennessee - Knoxville 4H2A TH 00054-06-04 Deaconess Billings Clinic Foundation 1D1B TM 00051-01-03 North Dakota State University 5H2A TM 00245-06-00 Integris Health 6H2A TM 00303-03-01 University of Kansas Medical Center 6D1B TM 00081-01-01 University of Vermont ii Foreword The German philosopher Schopenhauer (1788-1860) wrote: "There are three steps in the revelation of any truth: first, it is ridiculed; in the second, resisted; in the third, it is considered self-evident." Telehealth technologies have followed a similar fate. In the late 1980s and early 1990s, many looked on these technologies as "vaporware." Even today, resistance to widespread deployment of the technologies persists. Its comes from many quarters, reflecting challenges that range from provider concerns about quality of service and reimbursement to difficulties in integrating the technologies into day-to-day health care practice. It is only when sufficient experience has been gained with the use of these technologies that this picture will begin to change. Nevertheless, the uses of videoconferencing and imaging technologies in different areas of health care are expanding rapidly, from classic clinical encounters, such as dermatology or behavioral health, to home health care and rehabilitation services. Telehealth technologies, however, have not yet become "self-evident" in health care, that is, they have not become an integral part of mainstream health care. The challenges are significant, especially for community-based providers. Recognizing these challenges, 51 individuals came together to develop a basic document that would assist community- based providers in establishing a telehealth program. The result is the following document, which addresses 12 different applications of these technologies. The recommendations in each chapter are based on the real-life experiences of programs that often have been pioneers in the development of telehealth services for underserved communities. Given the rapid advances in telehealth technologies and the diversity of communities in the United States, the recommendations should be viewed as a starting point, not an end point, for implementing telehealth programs. This document was produced by a group of telehealth service providers who gave their time and effort because of their belief in telehealth technologies as a facilitator for more cost-effective health care services. The dedication of the individuals involved in this project represents the spirit of collaboration that is so essential to the telehealth field if it is to succeed. A special word of appreciation is extended to Joe Tracy, Executive Director of Telehealth at the University of Missouri Health Care, for his leadership and persistence on this project, despite many other constraints on his time. Finally, this document was funded under various grants awarded by the Office for the Advancement of Telehealth (OAT), Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services (DHHS). The views and opinions presented are those of the authors and various contributors to the chapters. They do not represent the official position of OAT, HRSA, or DHHS. Dena S. Puskin, Sc.D. Director Office for the Advancement of Telehealth HIV/AIDS Bureau Health Resources and Services Administration U.S. Department of Health and Human Services iii Chapter One Introduction Author: Joseph A. Tracy, MS, University of Missouri Health Care Contributing Authors: Thelma McClosky Armstrong, Eastern Montana Telemedicine Network Samuel Burgiss, PhD, University of Tennessee Graduate School of Medicine Susan Dimmick, PhD, University of Tennessee Graduate School of Medicine Karen Edison, MD, University of Missouri Health Care Michael A. Ricci, MD, University of Vermont College of Medicine Karen Rheuban, MD, University of Virginia Health System Cynthia Scheideman-Miller, MHA, Integris Health Richard J Settimo, MA Ed, University of Virginia Health System Rob Sprang, MBA, University of Kentucky Telehealth and telemedicine are becoming more and more engrained in the delivery of everyday healthcare, distance education and health care administration. Tens of thousands of patients in underserved Telemedicine is the use of electronic areas are receiving services they may not communication and information technologies to provide or support have otherwise received without traveling clinical care at a distance1. great distances or overcoming other Telehealth is defined as the use of transportation barriers. The services electronic information and provided via telemedicine range from telecommunications technologies to support long-distance clinical health primary care to the highly specialized care, patient and professional health- care found in leading academic medical related education, public health and health administration2. centers. Services are provided across the spectrum, from the youngest of patients to the frail elderly. Telehealth systems can be found in hospitals, clinics, nursing homes, rehabilitation hospitals, homes, assisted living facilities, schools, prisons, or health departments. In fact, today you may find telehealth systems any place healthcare is provided. 1 Introduction - Technical Assistance Documents J. Tracy, et al. Over the past 10 years the technologies needed to provide healthcare services at a distance have vastly improved and drastically dropped in price; reimbursement for telehealth is more broadly available than it was 10 years ago; and the cost of telecommunication services in many areas is much lower thanks to competition and the Federal Communication Commission’s Rural Health Care Support Mechanism (i.e., universal service fund), which provides discounts for telecommunications services provided by eligible rural healthcare facilities using telehealth technologies. These are just a few of the barriers that have been overcome, at least in part, to allow telehealth network expansion across the United States. The proliferation of telehealth programs has taught many lessons to those that have been engaged in telehealth activities since the early 90s. While this document focuses on telehealth delivery in underserved areas, the lessons learned apply to all communities. There are as many ways to configure and develop a telehealth network, as there are specialties to provide the service. There is no “standard” model, nor is there one right or wrong way for designing a telehealth network to provide care. The focus of this document is “telemedicine” as defined earlier or simply put the clinical application of providing care at a distance. The information contained within is designed to help those interested in entering the world