Activities in Telemedicine, Telehealth, and Health Technology

Federal Agencies:

By Carolyn Bloch

INTRODUCTION ...... 3 Dept. of Justice ...... 207

Executive Office of the President ...... 5 Dept. of Interior ...... 210 Dept.of Education ...... 211 Dept. of Labor ...... 213 FEDERAL AGENCIES Dept. of State ...... 214 Dept. of Homeland Security ...... 7 Dept. of Transportation...... 215 Dept. of Health and Human Services . . 13 National Institutes of Health ...... 21 Health Resources Services INDEPENDENT AGENCIES Administration ...... 49 AND COMMISSIONS Agency for Health Research Quality ...... 58 NASA ...... 216 Centers for Medicare and Medicaid ...... 68 National Science Foundation ...... 227 Centers for Disease FCC ...... 232 Control and Prevention ...... 77 Social Security Administration ...... 237 Substance Abuse and Mental Health Services Administration ...... 83 Federal Trade Commission ...... 238 Food and Drug Administration ...... 84 Office of Personnel Management . . . 239 Indian Health Service ...... 90 Consumer Products Safety Commission ...... 240 Dept. of Defense ...... 97 Appalachian Regional Army Telemedicine Activities ...... 115 Commission ...... 241 Navy Telemedicine Activities ...... 142 General Services Administration . . . . 243 Air Force Telemedicine Activities . . . . 150 Small Business Administration ...... 245 DARPA ...... 156 US Agency for Armed Forces Institute International Development ...... 246 of Pathology ...... 160 Uniformed Services University of the Health Services ...... 161 APPENDICES Dept. of Veterans Affairs ...... 165 Appendix A: Legislative Branch . . . . . 249 Dept. of Commerce ...... 186 Appendix B: Telemedicine Dept. of Agriculture...... 192 and Telehealth Web Sites ...... 253 Dept. of Energy ...... 195 About the Author ...... 254 3 Federal Activities in Telemedicine, Telehealth, and Health Technology

Introduction

The American Recovery and Reinvestment Act (ARRA) of 2009, referred to as the stimulus package, provides $19 billion for Health Information Technology Adoption. ARRA established the Health Information Technology for Economic and Clinical Health (HITECH) Act to support the development of health IT. ARRA funding for healthcare and research provides for:

• The HHS Office of the National Coordinator received $2 billion to coordinate health IT policy and programs. A HIT Policy committee assists HHS in forming a nationwide technology infrastructure and a separate HIT Standards Committee makes recommendations. • The HIT provisions to amend Medicare and Medicaid provide incentives to increase EHR adoption. These incentive payments go to physicians and hospitals, and several classes of Medicaid providers • ARRA provides temporary increases in Federal Medicaid to be contributed to all states • ARRA establishes a Federal Coordinating Council for Comparative Effectiveness Re- search to work with HHS, VA, and DOD and other Federal agencies to coordinate comparative effectiveness research across the Federal government. ARRA appropriated $300 million for AHRQ, $400 million for NIH, and $400 million for the Office of the Secretary of HHS to coordinate activities that relate to comparative effectiveness. $1.1 billion will be used to do research on clinical outcomes, and effectiveness for medical and health services. The funding will be used to provide for clinical registries, data networks, and other data that needs to be generated electronically. A report with recommendations has been released on how the funding will be spent. • Funds to help community health centers construct, renovate, obtain equipment, and health technology. HRSA received $2.5 billion with $500 million to go to community health centers • Funding to provide $500 million to help increase the primary healthcare workforce • Funding for $500 million will to go to the Indian Health Service. This funding includes $85 million for health information technology. These funds will go for telehealth services and infrastructure requirements • Provides for NIH to receive $10 billion for science and technology research projects

In the public health area, $650 million was funded for evidence-based clinical and community-based prevention and wellness strategies to deliver outcomes and address chronic disease rates. $300 million went to CDC’s immunization program and $50 million to implement healthcare-associated infections reduction strategies. The legislation provides funding for other agencies with responsibilities related to healthcare. $4.7 billion went to NTIA’s Broadband Technology Opportunities Program within the Department of Com- merce to provide for broadband services where needed. USDA Rural Utility Services will invest $2.5 billion in broadband. $150 million went to the Economic Development Administration. The National Institute of Standards and Technology received $220 million, $3 billion went to the National Science 4 Federal Activities in Telemedicine, Telehealth, and Health Technology

Foundation for science, engineering research and education, plus $500 million went to the Social Security Administration. Funding is available through the usual appropriations but in addition, the agencies also received ARRA funding. To receive grants, some research is needed to find funding to match your program activities and the specific areas where grant funding could be viable. Organizations need to look at all the possibilities such as finding sources for matching funds, opportunities to incorporate existing sources for funding with ARRA funds, and look at all possible partners such as community health centers, RHIOs, state HIT offices. The agencies involved in some way in telemedicine, telemonitoring, telehealth, health IT, informatics include the 13 cabinet-level departments and 11 independent and commissions listed in the table of contents to this report. As changes in the administration, personnel, and grant programs are announced, this information appears in the newsletter “Federal Telemedicine News”. You may either subscribe at (www.federaltele- medicine.com) or go to the blog at (http://telemedicinenews.blogspot.com), or subscribe through RSS feed. The information is updated two times a week. This report enables researchers, reporters, writers, scientists, industry, and other healthcare professionals to find information quickly and easily and to track the agencies and their activities in this ever-expanding field. If there are any, questions, or suggestions for new information to appear in future updates, please email [email protected]. 5 Federal Activities in Telemedicine, Telehealth, and Health Technology

EXECUTIVE OFFICE OF THE PRESIDENT Office of Science and Technology Policy National Coordination Office for ITR&D http://www.nitrd.gov The National Coordination Office (NCO) for Information Technology Research and Development plans and budgets activities for the Federal IT R&D program and researches future generations of information technologies. NCO reports to the White House Office of Science and Technology Policy and to the National Science and Technology Council. The NCO works with 12 participating Federal agencies through the Interagency Working Group on IT R&D to prepare and implement the IT R&D budget. The Human Computer Interaction and Information Management Coordinating Group focuses on information interaction, integration, and management research to develop and measure the performance of new technologies. The research supports healthcare, homeland security, emergency planning, and response. Congress enacted a three-year Next Generation Internet Initiative (NGI) and the Administration sponsored an Information Technology for the 21st Century Initiative (IT2). Both the NGI and IT2 initiatives were incorporated into the IT R&D program and are referred to as the Networking and Information Technology R&D (NITRD) program. Federally funded IT R&D provides assistance in times of terrorist attacks and disaster response. This includes using advanced technologies such as robotics, global positioning satellites, optical technologies, environmental monitoring, high-speed networking, computational chemical analysis, mapping, and simulation software. NITRD has focused IT research on cost effective high end computing to provide data storage and computing power for intelligence analysis, large scale data mining and information management technologies, advanced cryptography and authentication technologies, new methods to achieve security with high-speed wireless and wired devices, embedded networked sensor technologies, software for mission critical systems, and improved interfaces for and interoperability of IT devices. In 2009, the President’s Council of Advisors on Science and Technology (PCAST) met to develop recommendations to present to the President concerning science and technology including health IT. PCAST is administered by the Office of Science and Technology Policy. Also in 2009, PCAST published a report “Leadership Under Challenge: Information Technology R&D in a Competitive World”. The report assesses global U.S. competitiveness in networking and information technology. In 2009 PCAST published a report “U.S. Preparations for 2009-H1N1 Influenza” and PCAST’s Working Group detailed how the nation needs to respond to the problem and produced their own report on H1N1 with recommendations. In 2009, NITRD published the report “High Confidence Medical Devices: Cyber-Physical Systems for 21st Century Health Care. The report was a result of NITRD’s workshops that were held with more than 100 experts coming together to identify crucial challenges facing the design, manufacture, and the use of high confidence medical devices, software and systems. The Guide to the NITRD Program called the “blue book” is available to the public. The report published each year as a supplement to the President’s budget reports, describes the activities of the Federal agencies working together on advanced computing networking, software, and related IT. 6 Federal Activities in Telemedicine, Telehealth, and Health Technology

National Science and Technology Council Committee on Science Interagency Working Group on Digital Data In 2009, the Interagency Working Group published the report “Harnessing the Power of Digital Data for Science and Society” to examine how digital technologies are reshaping science and the tools that scientists need to deal effectively with the enormous amount of data. The Working Group has worked with nearly 30 agencies, offices, and councils to develop strategic requirements. 7 Federal Activities in Telemedicine, Telehealth, and Health Technology

FEDERAL AGENGIES Department of Homeland Security

http://www.dhs.gov The Department of Homeland Security (DHS) works in partnership with federal departments and agencies, state, local and tribal officials, the private sector, and national and international associations.

Office of Health Affairs http://www.dhs.gov/xabout/structure/editorial_0880.shtm The DHS Chief Medical Officer within the Office of Health Affairs (OHA) reports to the Secretary. The OHA is involved in WMD, biodefense, medical readiness, workforce health protection, and global health security. The OHA Medical Readiness Office identifies and evaluates DHS readiness programs and activities related to medical and public health, coordinates activities with the first health responder community, examines all regional hazards systems for medical and public health preparedness, coordinates with FEMA and HHS to develop risk-based performance objectives for health and medical capabilities, and coordinates medical and health preparedness grants. The OHA Medical Countermeasures Division within HHS provides expertise on countermeasures. The OHA works with HHS, Defense, Agriculture, Commerce, Transportation, Justice, the VA, CDC, EPA, and the U.S. Postal Service. OHA also works with state and local governments, non government organizations, and the private sector.

Preparedness Program http://www.dhs.gov/xprepresp The Preparedness program works with state, local, and private sector partners to identify threats and target necessary resources. DHS consolidates existing preparedness efforts such as grants, exercises, training, public health infrastructure, cyber security, and telecommunications.

Office for Emergency Communication http://www.dhs.gov/xabout/structure/gc_1189774174005.shtm The Office for Emergency Communications (OEC) responds to the department’s emergency preparedness and response functions. OEC combined the SAFECOM program, the interoperable communications technical assistance program, and parts of the integrated wireless network. The goal is to help the emergency response community provide security, reliability, scalability, and affordability for not only existing technologies but also for emerging technologies. The OEC has consolidated several interoperability programs and developed the National Emergency Communications Plan. Emergency Management Performance Grants go to support state and local emergency management programs. OEC is playing an important role in the Public Safety Interoperable Communications (PSIC) grant program. OEC provides technical assistance to the states to help them prepare their statewide interoperability plans and provides additional technical assistance. DHS conducts surveys of first responders across all jurisdictions to assess progress in achieving interoperable communications. 8 Federal Activities in Telemedicine, Telehealth, and Health Technology

SYSTEMS National Incident Management System http://www.fema.gov/emergency/nims/index.shtm The National Response Plan uses the National Incident Management System (NIMS) to establish standardized training, organization, and communications procedures for multi-jurisdictional interaction, and identifies authority and leadership responsibilities. NIMS is the first standardized management plan to create a unified structure for federal, state, and local lines of government for incident response and management. Key elements and features of NIMS include:

• Establishing an Incident Command System for operations planning, logistics, finance, and administration to better manage all major incidents • Using advanced preparedness measures to plan, train, examine qualifications and certifica- tions, buy equipment, and maintain publication management • Examining public education, enforcement of building standards and codes, and providing preventive measures to deter or lessen the loss of life or property • Prescribing interoperable communications systems for both incident and information management

Joint Information System The Joint Information System within NIMS provides the public with incident information, public messages, and brings incident communicators together during an incident to develop, coordinate, and deliver a unified message

National Biosurveillance Integration System The DHS studies the vulnerability of critical infrastructures such as food, water systems, agriculture, health systems and emergency services information, and telecommunications. The Bio-Surveillance Pro- gram initiative protects against bioterrorism and provides ongoing surveillance programs for health, hospitals, vaccines, food supplies, state and local preparedness, environmental monitoring. One component of the program will expand and deploy the next generation of technologies to the BioWatch Program. The National Biosurveillance Integration System can help with a possible flu pandemic. When an epidemic occurs, data is collected from CDC’s BioSense System which reports on syndromic surveillance, and other data is collected from several other sources to report on possible flu outbreaks or a bioterrorist attack. The DHS’s Homeland Security Information Network disperses biosurveillance trends and any threats to the proper authorities.

National Disaster Medical System NDMS coordinates how federal health officials respond to major emergencies, federally declared disasters, terrorist’s attacks, and domestic terrorist incidents involving weapons of mass destruction. Legislation was passed to make the Secretary of HHS responsible for public health and responses to emergencies. The preparedness and response programs are under the HHS Assistant Secretary for Pre- paredness and Response. 9 Federal Activities in Telemedicine, Telehealth, and Health Technology

Metropolitan Medical Response System The Metropolitan Medical Response System grants fund an integrated systematic mass casualty incident preparedness program to help first responders during the first crucial hours of an incident. This program provides funding on a formula basis to 124 MMRS jurisdictions.

Directorate for Science and Technology http://www.dhs.gov/xabout/structure/editorial_0530.shtm The Directorate is the primary research and development arm to drive development and the use of high technology to support homeland security. The Directorate draws upon technologies that can be developed and delivered within three years. The goals are to develop and deploy state-of-the-art low cost systems to protect against terrorist attacks, develop technology standards, and establish certified laboratories to evaluate technology for “Safety Act” certification. The Science and Technology Office for Innovation is responsible for examining all the DHS technologies. The technology will be used to create a resistant electronic grid to protect critical infrastructure sites. The Office of Interagency Programs and First Responder Liaison works closely with DOD to develop information sharing opportunities. DHS provides national interagency outreach through meetings, conferences, and symposia. The “Coordination of Homeland Security Science and Technology” document provides the direction for DHS research and development, and identifies strategic goals through 2015 to help to adapt to a changing world and ever evolving enemy. The Office has published a 5 year plan from 2008-2013 for research and development and published a report in May 2009 outlining high priority technology needs. There is information on first responder, chemical/biological defense, and incident management technology needs.

TechSolutions www.dhs.gov/techsolutions The Tech Solutions Program was established by the Science and Technology Directorate to provide information, and help find the resources and technology solutions to identify gaps that are recognized by the emergency response community. Tech Solution looks at technological requirements and provides solutions for first responders. First responders are encouraged to submit ideas that would help the first responder community to increase efficiency and on-the-job-safety. The Homeland Security Advanced Research Project Agency (HSARPA) housed within the Direc- torate is the external funding arm of the Science and Technology Directorate. HSARPA’s purpose is to perform early research and development on the scientific and biological front. Other offices within the Directorate include the Office of Plans, Programs and Requirements, Office of R&D, and the Office of Systems Engineering and Development. The agency awards research grants.

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OTHER PROGRAMS Regional Technology Integration Initiative The Regional Technology Integration (RTI) Initiative works to transition innovative technologies and organizational concepts to regional, state, and local jurisdictions. Four urban areas were selected to be the initial pilot locations in the program. The program has an initial investment of $10 million for studies and assessments. Subsequent funding for the deployment of technology systems will be determined after looking at the results of initial studies and working in collaboration with the selected urban areas. Cincinnati Ohio one of the four locations, enables public health officials, fire departments, and law enforcement to be in contact through a one million dollar command center.

Advisory Committees and Collaborative Agreements The Homeland Security Science and Technology Advisory Committee, operates with a technology clearinghouse, the Office for National Laboratories, and an office to handle extramural programs with universities. The National Infrastructure Advisory Committee provides information on the security of information systems for public and private institutions.

Federal Emergency Management Agency http://www.fema.gov FEMA is involved in disaster management responds to hazards, mobilizes personnel to help with safety, and coordinates disaster response teams. FEMA has the authority to designate specialized teams for emergency communications and to assist in medical emergencies. FEMA wants to obtain new technologies and equipment to improve disaster readiness. DHS is using satellite imagery, upgrading radios, and employing frequency management. The National Response Coor- dination Center at FEMA and Mobile Registration Intake Centers are operational. FEMA also coordinates the National Emergency Response Team a part of the National Disaster Response Teams (NDRT) and part of the National Disaster Medical Systems of the U.S. Public Health Service. The NDRT teams include physicians, nurses, and paramedics, coordinated by FEMA.

DHS Assistance for Industry Small Business Program http://www.dhs.gov/openforbusiness DHS has a small business specialist in each contracting office, conducts monthly vendor outreach sessions, participates in small business conferences, has a mentor-protégé program, awards small business contracts, and provides a business website. The program “Open for Business” assists the business community and provides links to contracts, grants, small business opportunities, and R&D contracts. The Information Technology Acquisition Cen- ter establishes department-wide contacts for IT services and commodities under the program names of EAGLE and First Source. EAGLE is a partial small business set-aside for software development, engineering design and development management support services, and operation and maintenance. First Source, a 100 percent small business set aside provides the agency with a variety of commer- 11 Federal Activities in Telemedicine, Telehealth, and Health Technology

cial catalogs for IT commodity products. The contracts include IT equipment and software, networking, wireless technology, imaging products, voice recognition technology, and online data reporting services. The goal is to explore network technologies that can forward real-time information about a specific first responder from a flexible array of multiple sensors to a receiver.

Commercial Equipment Direct Assistance Program http://www.rkb.us CEDAP operated by the Office of State and Local Government Coordination and Preparedness, provides technology, installation, and technical assistance directly to eligible jurisdictions. DHS is distributing commercial IT and sharing software with first responders and offers sensors and risk management software. FEMA has awarded millions in equipment and equipment training. Eligibility for the grants is limited to law enforcement agencies, fire, and other emergency responder organizations. The awards are offered in personal protective equipment, thermal imaging, night vision, video surveillance tools, chemical and biological detection tools, information technology and risk management tools, and interoperable communications equipment.

Technology Transfer Clearing House http://www.fema.gov/rebuild/mat/mat_trans.shtm The Clearing House has information on public health and a community database on technology transfer. A contract was awarded to PSITEC to provide services through the knowledge portal to provide one stop shopping.

SBIR Program http://www.dhs.gov/xres/grants/#1 The HSARPA SBIR program is restricted to for-profit small businesses with 500 or fewer employees. Firms with successful concepts in Phase 1 may be invited to apply for a two-year Phase 2 award not to exceed $750,000 to further develop the concept, usually to the prototype stage. For example, EyeMarker Systems received SBIR funding from DOD to develop an ocular imaging device to detect toxins in the system, if terrorist’s attacks should become more deadly with the use of more chemical and biological agents. DARPA helped the company acquire additional funding from the interagency Technical Support Working Group to get the device ready for commercialization. The Sci- ence and Technology Directorate within DHS partnered with TSWG to add funding for additional software development and testing.

Future TECH http://www.dhs.gov/files/programs/gc_1242058794349.shtm The DHS TECH program was established to develop mutually beneficial partnerships with the private sector, national laboratories, university community, and other R&D organizations. The goal is to develop technologies and capabilities to address the long term needs of DHS. Future TECH enables the private sector and others to find out about the critical research and innovation focus areas of interest to the Science and Technology Directorate. 12 Federal Activities in Telemedicine, Telehealth, and Health Technology

Technical Support Working Group http://www.tswg.gov TSWG is helping the private sector develop technologies and systems needed for homeland security. TSWG looks for new technologies that will detect hazardous biological and chemical agents and to further develop handheld detectors. The S&T Directorate coordinates research and development projects with TSWG to combat terrorism. Several DHS funded tasks addressing S&T requirements were funded through TSWG.

Vendor Information Site http://vendors.dhs.gov/dhspsi/index DHS has created a Vendor Information Site with a database so that businesses can share information about their information technology related products and services. This helps DHS develop partnerships with the private sector to research, develop, and deploy homeland security technologies. The agency retains the information for reference purposes in order to understand IT products and services that may meet emerging requirements through procurements undertaken or that will be undertaken.

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Department of Health and Human Services http://www.dhhs.gov Office of the Secretary

http://www.os.dhhs.gov

Healthcare Reform http://www.healthreform.gov HHS released the report “Americans Speak on Health Reform: Report on Health Care Community Discussions” in 2009. The report summarized comments from many Americans who participated in Health Care Community Discussions across the country. The web site enables Americans to share their thoughts about health reform with the Obama Administration. In 2009, the Secretary established the Office of Health Reform to spearhead the passage of health reform and to coordinate closely with the White House Office of Health Reform.

Office of Recovery Act Coordination http://www.hhs.gov/recovery The Office was created to help organize and distribute an estimated $137 billion in Recovery Act Funds to be managed by HHS. A Deputy Assistant Secretary for Recovery Act Coordination was put in place to obtain critical resources and provide potential new job opportunities.

Office of the National Coordinator for Health Technology http://www.healthit.hhs.gov The Office of the National Coordinator for Health Technology (ONC) coordinates the nation’s health information technology efforts, and operates under the leadership of four permanent directors.

2009 Stimulus Package Funds ONC received $2 billion to coordinate health IT policy and programs. The programs will be initiated by the Secretary but the National Coordinator will have the responsibility to move and expand the electronic movement of health information. Vice President Joe Biden in 2009 announced that $1.2 billion in grant funding will be used to help hospitals and healthcare providers implement and use electronic health records. The rollout provides for two HITECH priority grants programs to establish Health Information Technology Regional Extension Centers and grants to help States and Qualified State Designated Entities share information within the emerging nationwide system of networks. The initial funding of $598 million will ensure that comprehensive support is available to providers beginning early in FY 2010 with an additional $5 million available for years 3 and 4 of the program. Federal support will continue for four years and then the program is expected to be self sustaining. The State Health Information Exchange Grant program with funding of $564 million is awarding cooperative agreements to states and qualified state designated entities to advance information sharing 14 Federal Activities in Telemedicine, Telehealth, and Health Technology

across the healthcare system. States will need to match grant awards beginning in 2011. The ONC has awarded grants to states and Indian Tribes. There are incentive grants to use for HIT for infrastructure and tools for the promotion of telemedicine, and state planning and implementation grants. There is also grant money to set up a national research center and regional extension centers. Grants in consultation with NSF will be provided for demonstration projects to help move and integrate certified EHR technology into clinical education. Loans will be provided through a technology loan program to help providers. Loans may be used by providers to purchase certified EHR technology, improve EHR technology, to train personal to use the new technology and to improve the secure electronic exchange of health information. These loans will be available in 2010. ONC released the Federal Health IT Strategic Plan 2008-20012 to advance HIT. With the passage of the Recovery Act the plan will be revised by ONC. The plan identifies the federal activities needed to implement the technology infrastructure in both the public and private sectors. The two primary goals are to help Patient Focused Health Care and Population Health. The plan describes 43 strategies needed to achieve each objective. The plan addresses privacy, security, achieving an interoperable health IT architecture, how to accelerate IT adoption, and how to foster collaborative governance.

Other ONC Activities • ONC is working to integrate HIT in education and include EHR in medical school curricula. The agency is working with NSF on workforce training for HIT professionals • The Office of the National Coordinator for HIT provides Use Cases, and is interested in feedback by interested stakeholders by both the private and public sectors. The use cases are both Prototype Use Cases and Detailed Use Cases • ONC awarded $450,000 to Booz Allen Hamilton to assess and evaluate the scope of the medical identity theft problem in the U.S. and examine how health IT can be used to detect and prevent medical identity theft

NHIN HHS and other agencies are working together to develop and connect to the NHIN. The Federal Health Architecture led by ONC is working with 26 federal agencies with health related activities to advance health information exchange across the federal government and with tribal, state, and private sectors. Contracts were awarded to nine health information exchanges to begin NHIN trial implementa- tions. These trials will demonstrate core services, exchange summary patient records, and support the capabilities of NHIN. Further contracts with CDC will further develop NHIN. Several major contracts were awarded for standards development, for developing requirements for health IT products, developing models and prototypes for NHIN to be used for health information exchange, and to assess variations in state laws and organization. In 2009, NHIN made software called CONNECT available to help public and private health information technology systems communicate to NHIN. NHIN came online and started exchanging live data among those organizations that are ready, willing and able to exchange health information using NHIN specifications and standards. The first agency to use NHIN was SSA to speed up applying for SSA disability benefits. DOD, VA, CDC, IHS, and NCI have also tested and demonstrated CONNECT”S ability to share data. 15 Federal Activities in Telemedicine, Telehealth, and Health Technology

Federal Health Architecture Office The Office is developing a version of the CONNECT software to help expand the sharing of health information between Medicaid and other state health offices and with federal and commercial health service agencies.

Federal Multi-Agency Activity The 2009 stimulus package establishes a Federal Coordinating Council for Comparative Effec- tiveness Research to assist HHS, VA, DOD, and other agencies to coordinate and conduct comparative effectiveness and related health services research. In addition, a Federal Interdepartmental Health Infor- mation Technology Collaborative brings together leaders in the federal departments engaged in health IT programs. Federal agencies included in the collaborative are USDA, Department of Commerce, HHS, FCC, FTC, NASA, and NSF. The Federal Health Architecture Program supports federal health IT by providing a federal framework that is interoperable within the federal government and works with other public and private sector organizations.

Standards Development ONC supports the harmonization of standards needed. HITSP is conducting the ONC funded project. There are more than 300 health related organizations working together to identify and harmonize data and technical standards for health IT. ONC set up the Certification Commission for Healthcare Information Technology (CCHIT) to develop the evaluation process for certifying electronic health records. A number of vendors now have earned certification for electronic health record products from CCHIT, and the numbers keeps growing. A web site (http://xreg2.nist.gov/hit-testing) developed in partnership with HITSP, NIST, ONCHIT, provides access to tools and resources. The 2009 stimulus funding gives the National Coordinator the responsibility for standards and certification. New health IT Policy and HIT standards committee are being formed to serve as federal advisory committees

Disparities in Populations A collaborative was formed to develop e-health related solutions to alleviate health disparities in underserved rural and urban communities. The “National Health IT Collaborative for the Underserved” was formed with HHS/Office of Minority Health, the Institute for e-Health Policy, Summit Health Insti- tute for Research and Education, Inc. Association of Clinicians for the Underserved, and Apptis to help to those areas in need. ONC serves on the HHS Workgroup on Health IT and Underserved Populations to assess ongoing activities, challenges, and opportunities to help reduce disparities in populations. The workgroup is chaired by the Office of Minority Health and HRSA.

Developing HIEs in States ONC in conjunction with the Foundation of Research and Education, part of AHIMA will research 16 Federal Activities in Telemedicine, Telehealth, and Health Technology

and report on state level Health Information Exchanges. State HIEs need to work with state governments and others to identify and remove barriers for medically underserved participation in health information exchanges. The State Alliance for e-Health was designed to build state government consensus across jurisdictions on many issues related to HIE, and is composed of state governors, legislators, high level officials and technical experts.

Privacy and Security Policies The Privacy and Security Solutions contract awarded to RTI International and co-managed by ONC and AHRQ coordinates the work of 33 states and one territory to establish the Health Information Secu- rity and Privacy Collaboration (HISPC) along with a broad range of stakeholders to assess current variations in state level privacy and security practices.

Advisory Committees National Biodefense Science Board http://www.gov/aspr/omsph/nbsb A Public Health Advisory Board advises the Secretary on Chemical, Biological, or Radiological Agents. The National Biodefense Science Board advises on preventing, preparing, and how to respond to the release of agents, trends, challenges, and opportunities in the field.

National Committee on Vital and Health Statistics http://www.ncvhs.hhs.gov The Committee is a public advisory body to the Secretary on health data and statistics and serves as a forum with private sector groups on a variety of key health data issues. These issues include health statistics, electronic interchange of healthcare information, privacy and security, purchasing or financing of healthcare services, integrating computerized health information systems, health services research, consumer interests, health data standards, e-prescribing standards, and uniform standards for patient medical record information.

Advisory Committee on Regulatory Reform http://www.regreform.hhs.gov The committee provides the Secretary with recommendations regarding potential regulatory changes to reduce burdens and costs associated with departmental regulations. The committee makes recommendations in healthcare delivery, health systems operations, biomedical and health research, and developing pharmaceuticals and other products.

National Advisory Committee on Rural Health and Human Services http://ruralcommittee.hrsa.gov The National Advisory Committee on Rural Health and Human Services is a 21 member panel of experts providing recommendations and reports to the Secretary. The Committee pointed to the need for 17 Federal Activities in Telemedicine, Telehealth, and Health Technology

research in substance abuse and the need to use technology to help solve this enormous problem in rural areas.

Additional Activities at HHS • In 2009, ARRA funds to be administered by CMS went to 12 states to survey more than 125 ambulatory surgical centers before September 30, 2009. In October 2009, additional funds went to all of the states to make inspections of ASCs. CDC made $40 million available for state public health departments to create or expand state-based HAI prevention and surveillance efforts. • Researchers are studying how to integrate genomics into clinical information systems so that physicians will know their patients genetic makeup • HHS has outlined a Personalized Health Care Initiative to combine the basic scientific breakthroughs of the human genome with the computer to exchange and manage data. The agency has released a second report that looks at findings in genetics and other molecular level medicine • HHS has developed a new downloadable online, diagnostic, and treatment toolkit designed for healthcare providers, primarily physicians who may have to provide medical care during a radiation incident • HHS has established a Patient Safety Task Force to coordinate efforts among several department agencies to improve patient safety data collection. The Federal agencies include AHRQ, the Centers for Disease Control and Prevention, FDA, and Centers for Medicare and Medicaid. The task force is building a Medicare patient safety monitoring system that the agency will use to gather information from medical and administrative records • HHS has established Patient Safety Organizations to allow for the voluntary reporting of patient safety events without fear. A final rule effective January 2009 provides for final requirements and procedures for PSOs and new entities • HHS Office of Inspector General and CMS announced final regulations to support physician adoption of electronic prescribing and electronic health records technology. The final rules create new exceptions and safe harbors to two federal fraud and abuse laws that involve electronic health information technology and services. The exceptions and safe harbors allow for donations to physicians of interoperable electronic health records software, IT, and training services, plus hospitals may provide physicians with technology to be used solely for electronic prescribing

Assistant Secretary for Health http://www.hhs.gov/ash

Office of Public Health and Science http://www.dhhs.gov/ophs The Assistant Secretary for Health advises the Secretary on public health and oversees the U.S. Pub- lic Health Service. The Office of Public Health and Science within the Office of the Assistant Secretary for Health is working to improve infectious disease surveillance, improve connectivity between hospitals 18 Federal Activities in Telemedicine, Telehealth, and Health Technology

and health departments, help hospitals with casualties, and help to expand public health laboratories. The Laboratory Response Network, a system of over 80 public health laboratories identifies pathogens that could cause bioterrorism. The Assistant Secretary for Health showcases best practices in public health from all over the country with information on Houston Texas, Boston Medical Center, Utah Department of Health, Massa- chusetts Department of Public Health, Michigan Department of Community Health, and the Rhode Island Department of Health. OPHS has a plan to reduce and possible eliminate healthcare associated infections. The document “Action Plan to Prevent Health Care Associated Infections” lists areas where HAIs can be prevented and also outlines cross agency efforts to initiate HAI prevention efforts.

Office of Disease Prevention and Health Programs (ODPHP) http://odphp.osophs.dhhs.gov The Office of Disease Prevention and Health Programs (ODPHP) under the direction of the Office of Public Health and Science, conducts the “Developing a National Action Agenda for the National Health Information Infrastructure (NHII)” conference. The NHII addresses information and communication technologies to advance personal health, population health, prevention, and healthcare. ODPHP is involved in a number of other initiatives:

• Steps to a Healthier US (STEPS) is an initiative to help Americans live longer, better, and healthier, and identifies and promotes healthy behaviors and prevention. Priority areas for the initiative are diabetes, obesity, asthma, heart disease, stroke, and cancer. • The National Health Information Center (NHIC) is an internet accessible clearinghouse with a toll free number that provides a central health information referral service for consumers and professionals using a database of national associations, government agencies, and other organizations. ODPHP publishes the directory of Federal Health Information Centers and Clearinghouses compiled annually by NHIC • The Healthy People 2010 Program promotes health and has established health improvement objectives with ten year targets. • Healthfinder (http://www.healthfinder.gov) links consumers and professionals to information from the federal government and many partners. The department wide project includes resources on over 1000 topics

Assistant Secretary for Preparedness and Response http://www.hhs.gov/asphep The Assistant Secretary for Public Health and Emergency Preparedness (ASPHEP) advises the Sec- retary on bioterrorism and other public health emergencies. ASPHEP coordinates activities between HHS and other federal departments, agencies, and offices responsible for emergency preparedness. Funding is provided to increase hospital preparedness in the states, territories, and metropolitan areas. HHS established the Biological Advanced Research and Development Authority (BARDA) to fund the advanced development of medical countermeasures. BARDA coordinates interagency efforts to define and prioritize requirements for public health medical emergency countermeasures related to research, 19 Federal Activities in Telemedicine, Telehealth, and Health Technology product development, and procurement. BARDA manages Project BioShield as well as manages the advanced development and procurement of medical countermeasures for pandemic influenza and other emerging infectious diseases that fall outside the auspices of Project BioShield. The Assistant Secretary through the Hospital Preparedness Program is funding ways to improve the readiness of hospitals and other healthcare organizations. The goal is to develop interoperable communication systems, track available hospital beds electronically, register volunteer health professionals, develop procedures for hospital evacuations, and provide for fatality management. The Emergency Care Coordination Center (ECCC) is located in the Assistant Secretary’s office. The ECCC supports the coordination of in-hospital emergency medical care activities and promotes programs and resources to improve the delivery of emergency medical care and emergency behavioral health care. The program is looking for the best approaches to support regionalized, comprehensive, and accountable emergency care and trauma systems. The ECCC is planning on developing demonstration programs in this field.

Other HHS Bioterrorism and Collaborative Efforts

• PAHPA calls for the Secretary to establish a near real-time electronic nationwide public health situational awareness capability through an interoperable network of systems • HHS has a national epidemiologic surveillance system based on state, regional, and community-level capabilities. The network enables information flow among all entities to help in health emergencies and disasters if bioterrorism occurs. • A Command Center monitors public health and coordinates HHS activities with international, federal, state, and local public health authorities during emergencies • CDC, FDA, DHS, and USDA are working together on the Bio-Surveillance Initiative. The goal is to develop new tools and procedures to identify potential disease outbreaks more rapidly • HHS has awarded funds to states, territories, and major metropolitan areas to help hospitals and other healthcare facilities respond to bioterrorism attacks, infectious diseases, and natural disasters that may cause mass casualties. The funds are used to provide or improve interoperable communications systems to track available hospital beds, and plan for both fatality management and hospital evacuations • HHS initiated the “Healthcare Facilities Partnership Program” to award grants to enable healthcare partnerships to prepare for public health emergencies. The program focuses on hospital surge capacity and emergency care system capability.

Assistant Secretary for Administration http://www.hhs.gov/asam

Office of Grants Management and Policy http://www.hhs.gov/og 20 Federal Activities in Telemedicine, Telehealth, and Health Technology

Federal E-Health Initiative http://www.grants.gov HHS is the managing partner for the Federal E-Grants Initiative, one of 24 initiatives of the overall E-Government program to improve access to government services via the internet. Eleven departments and agencies have been designated as supporting partners to develop a one-stop electronic grant portal where potential grant recipients receive full service electronic grant administration. The first step in searching for grant opportunities is to register and receive automatic email notifications of new grant opportunities as they are posted on the site. The next step is to download an application package and register with the Central Contractor Registry online, and the third step is to register the organization’s E-Business Point of Contact, confirm the CCR Marketing Partner ID password, and the last step is to register the Authorized Organization Representative.

Grantsnet http://www.hhs.gov/grantsnet Grantsnet is an internet application tool developed to provide information on HHS grants and other Federal grant programs. HHS does not have one publication that describes all of HHS grants and programs, The agency uses the Catalog for Federal Domestic Assistance to profile all Federal grant programs, and publishes information on (http://www.grants.gov) and on the agency web sites.

TAGGS http://taggs.hhs.gov The Tracking Accountability in Government Grants System (TAGGS) is a tool developed by the HHS Office of Grants with a database on grants that have been awarded by the 12 HHS Operating Divi- sions. Information is available by keyword and by doing an advanced search.

Assistant Secretary for Financial Resources http://www.hhs.gov/asrt As of 2009, the Office provides advice and guidance on budget issues, financial management, information technology, grants, and ARRA coordination. Before 2009, the office was known as the Assistant Secretary for Resources and Technology. This office now has responsibility for the Office of Small and Disadvantaged Business Utilization.

Assistant Secretary for Planning and Evaluation http://www.hhs.gov/aspe ASPE has funded a number of studies related to health IT and provides an analysis of costs and benefits, an analysis of consumer control of personal electronic health information, an economic assessment of small physician practices adoption of EMRs, and studies examining the exchange of health information for persons receiving long term care. ASPE analyzes and models factors associated with successful EHR adoption and evaluation. 21 Federal Activities in Telemedicine, Telehealth, and Health Technology

Technology for Long Term Care The HHS office studies technologies that are available to provide higher quality care for the elderly and the disabled. The information is available for professionals in nursing homes, assisted living facilities, adult day care facilities, and continuing care retirement communities.

Office of Global Health Affairs http://www.globalhealth.gov The site has information on global health issues as well as worldwide health statistics for reports and publications and provides links to global health partners. The Office has funded a cooperative agreement with the Arizona Department of Health Services, and the Arizona Outreach Office of the U.S. Mexico Border Health Commission to strengthen the bi-national public health projects and programs along the Arizona-Sonora border. The program is working with the Arizona Department of Health Services, Office of Border Health, the Secretaria de Salud de Sonora, and the USMBHC Arizona and Sonora Delegation Offices. The office works on data analysis, public information, communication and Health Gente/Health Border 2020 activities.

Office of Inspector General http://oig.hhs.gov The Office of Inspector General (OIG) provides oversight for patient safety grants, local health departments bioterrorism preparedness, state laboratory response networks, health alert networks, reportable disease surveillance, national electronic disease surveillance systems, hospital bioterrorism preparedness programs, urban Indian health programs, research grants, and medical records privacy. Goals are to study smart card technology, examine how State Medicaid agencies will use health IT, study the Clinical Trials Data Bank to see if complete information is received, examine the Adverse Event Reporting for Medical Devices System, and assess the Quality Improvement Organization program.

Council on Private Sector Initiatives to Improve Security, Safety, and Quality of Health Care The Council reviews requests from companies that have innovative ideas and products to sell to the government and looks for products to enhance security, safety, and quality of the nation’s healthcare system including bioterrorism preparedness.

NATIONAL INSTITUTES OF HEALTH

http://www.nih.gov

NIH Challenge Grants in Health and Science Research As part of the Recovery Act, NIH is funding at least $200 million in FY 2009-2010 for this new grant initiative. The program supports research on “Challenge Topics” to address specific scientific and 22 Federal Activities in Telemedicine, Telehealth, and Health Technology

health research challenges in biomedical and behavioral research. Some of the topics focus on new technologies, enhancing clinical trials, health disparities, information technology for processing healthcare data, science, technology, engineering and mathematics education, smart biomaterials, and translational science.

“GO” Grants In 2009, as part of the Recovery Act funds, NIH and the individual institutes started funding a program called Research and Research Infrastructure “Grand Opportunities” that is referred to as the “GO grant program. NIH seeks projects that will have a high short-term impact and provide for growth and investment in biomedical research to further develop public health, and healthcare delivery.

Community Infrastructure Grants The new “Community Infrastructure Grants Program” has up to $30 million in fiscal years 2009- 2010 to fund 30 or more grants. The grant program supported by the Recovery Act will develop, expand, or reconfigure the infrastructure needed to enable academic health centers and community-based organizations to collaborate on health science research.

Roadmap for Medical Research Initiative The Roadmap for Medical Research Initiative involves all of the NIH institutes and centers and targets research gaps and opportunities that no other single NIH institute can solve alone. The initiative is set up in three core themes to establish new pathways to build biological databases and other research tools, invent the research teams of the future, and re-engineer the clinical research enterprise. As part of the Roadmap, the Human Micro Biome Project has awarded $115 million to researchers to sequence 600 microbial genomes to complete a collection totaling some 1,000 human micro biome genomes.

Global Initiatives The Obama Administration has pledged $63 billion for the Global Health Initiative and is now moving ahead. The Trans-NIH Global Health Research Working Group has been formed to analyze global health research activities at NIH and to find better ways to coordinate efforts across NIH and throughout the government.

Clinical and Translational Science Consortium The Consortium lead by NCRR is a national network of medical research institutions working together to accelerate the process for turning laboratory discoveries into treatments for patients, to engage communities in clinical research efforts, and to train the next generation of clinical and translational researchers. NIH funds the NIH Roadmap Epigenomics Program and is going to invest more than $190 million over the next five years to accelerate this emerging field of biomedical research. The awards focus on epigenome mapping centers, epigenomics data analysis and coordination, technology development, and the discovery of novel epigenetic marks in mammalian cells. 23 Federal Activities in Telemedicine, Telehealth, and Health Technology

Office of Portfolio Analysis and Strategic Initiatives The T-ROI program was announced to support exceptionally innovative, original or unconventional research to cultivate bold new ideas regardless of the risk. New studies are supported on biomedical or behavioral sciences, complex 3D tissue models, acute to chronic pain transition, and pharmacogenom- ics. The T-ROI program is a trans-NIH effort coordinated by OPASA and is part of the NIH Roadmap for Medical Research. NIH intends to invest more than $250 million over the next five years.

Initiatives • NIH’s Radiology and Imaging Sciences at the Clinical Center are taking steps to safegu- rard patients who are exposed to radiation during certain imaging tests. Computed tomography and positron emission tomography equipment is now required at NIH to routinely record radiation dose exposure to be included in a patient’s hospital-based electronic medical record • NIH’s Health Blueprint for Neuroscience Research launched a $30 million project to use cutting edge brain imaging technologies to map the circuitry of the healthy adult human brain. The project is called the Human Connectome Project • NIH issued PA-07-295 to study the impact that health IT has on health interventions and services, and is looking for studies related to the impact of technology on the delivery of health related information as well as health related clinical interventions • NIH established three Government-Wide Acquisition Contracts called (GWACS) to support IT needs across NIH • The NIH Roadmap Initiative for Bioinformatics and Computational Biology awarded a five year cooperative agreement to the National Alliance of Medical Image Computing, a $20 million national center for biomedical computing to adopt ITK and its software as part of its engineering core. The 3D Informatics Program continues to develop in-house research efforts and is doing systems trials using ITK and haptic latency analysis for surgical simulation • NIH has established a Molecular Libraries Screening Center Network to identify small molecules to be used as research tools • The Office of Portfolio Analysis and Strategic Initiatives is collecting data on various diseases, conditions, and research fields. The staff seeks broad public input from healthcare providers, policymakers, scientists, plus advice from NIH

Genetic Modification Clinical Research Information System http://www.gemcris.od.nih.gov NIH and FDA have developed a Genetic Modification Clinical Research Information System (GeMCRIS) a web accessible database on human gene transfer. GeMCRIS is a public information resource as well as an electronic tool to facilitate the reporting and analysis of adverse events on trials. The system provides information directly to the public and enables the government to monitor adverse events in gene transfer research. 24 Federal Activities in Telemedicine, Telehealth, and Health Technology

OFFICE OF THE DIRECTOR Biomedical Information Science and Technology Initiative (BISTI) http://www.bisti.nih.gov BISTI brings together interdisciplinary teams of researchers to develop math models, write software, adapt systems, and produce new ideas with a cross disciplinary focus. The intent is to define fiscal responsibility and share this responsibility among other institutions. BISTI has established national programs of excellence in biomedical computing as part of the Roadmap initiative, and National Centers for Biomedical Computing (NCBC). The NCBCs are interested in all facets of biomedical computing from basic research in computational science, to providing the tools and resources to biomedical behavioral researchers to do their work. To help carry out fundamental research, plans are to educate and train researchers to engage in biomedical computing. One center led by Partners HealthCare System, tests developments on diabetes mellitus, asthma, hypertension, and Huntington’s disease. After the initial NCBCs have been funded, NIH will support partnerships between individual investigators and the centers. For example, a biomedical research laboratory with software that is useful in modeling the function of the heart, might seek to use the expertise of the NCBC to modify the software to run on a computational grid. Alternatively, the biomedical researcher might seek support from the NIH NCBC to design and build hardware that would be well suited to solve their program. Other programs within BISTI are directed toward information storage and retrieval, providing support to researchers inventing, refining, and applying tools of biomedical computing, along with fostering a scalable national computer infrastructure. The Office of Behavioral and Social Sciences Research in the Office of the Director has launched a web http://obssr.od.nih.gov that provides key information on behavioral and social science research activities at NIH.

National Institute of Biomedical Imaging and Bioengineering http://www.nibib.nih.gov The NIBIB supports research that applies engineering and imaging science to biological processes, disorders, and diseases. The Institute coordinates NIH research and fosters the exchange of information with other federal agencies. An advisory council of 12 scientists, engineers, physicians, and other health professionals consult with the director. Half of the members are from the present disciplines in biomedical imaging and bioengineering, with the other half representing other disciplines. An Advisory Board of Scientific Counselors has been established. The Committee advises on intramural research programs and visits laboratories to assess research in progress, proposed research, and to evaluate the productivity of the staff scientists and physicians. NIBIB and the National Center on Minority Health and Health Disparities are developing joint programs so that medical technologies can be used to address disparities in healthcare access and health outcomes. NIBIB and the Department of Biotechnology of the Ministry of Science and Technology of the Re- public of India are developing low cost healthcare technologies aimed at the medically underserved. They 25 Federal Activities in Telemedicine, Telehealth, and Health Technology

are exploring telehealth and telecommunication technologies, x-ray technology, nanotechnology based biosensors, point of care diagnostic technologies, and neonatal health technologies. Researchers at NIH and the University of Arkansas for Medical Sciences are working on developing a laser and an ultrasound transducer to enable researchers to listen for both normal and abnormal cells flowing though the lymphatic system. This diagnostic tool when fully developed may be able to detect cancer and other diseases before they become life-threatening.

Point-of-Care Technologies Research Network NIBIB, NHLBI, and NSF established the POC Technologies Research Network and now four universities are working together to develop POC technologies. The University of California Davis is developing POC instruments for critical emergency disaster care, Johns Hopkins is developing POC technologies to test for STDs, the University of Cincinnati is developing POC testing for emergency room doctors needing information related to neurologic emergencies, and Path at the University of Washington is developing POC devices to help in global healthcare.

Some of the Grant Programs • The Small Grant Funding Opportunity supports well defined small research projects that can be carried out in two years with limited resources. The funding supports pilot and feasibility studies, small self contained research projects, and the development of new research technology • The Quantum Grants Program funds advances in healthcare by funding research on targeted projects to develop new technologies for the diagnosis, treatment, or prevention of disease. • Exploratory Developmental Grants (R21) are awarded in the telehealth field to support the design and development of novel telehealth instrumentation or technologies that can be applied to a broad spectrum of disorders and diseases • NLM, NIMH, and the National Institute of Biomedical Imaging and Bioengineering, award Informatics for Disaster Management Grants

Laboratory for the Assessment of Medical Imaging Systems NIBIB and the FDA’s Center for Devices and Radiological Health have signed an interagency agreement to establish a joint Laboratory for the Assessment of Medical Imaging Systems (LAMIS). The joint effort assesses high resolution, and high dimensional medical imaging systems.

Bioengineering Consortium (BECON) http://www.becon.nih.gov/becon.htm BECON provides understanding between the biological, medical, engineering, and physical sciences, and is the focus for bioengineering issues at NIH. BECON is composed of senior-level representatives from each of the NIH centers, institutes, and divisions, and works with other federal agencies on biomedical research and development. The NIH Bioengineering Research Partnership Program (BRP) does basic bioengineering research on biological or medical problems. Multidisciplinary research teams study preventing, detecting, diag- 26 Federal Activities in Telemedicine, Telehealth, and Health Technology

nosing, treating diseases, and understanding health behavior. Some of the areas under consideration are nanotechnologies for drug and gene delivery vehicles, multi-scale modeling in biomedical systems, and sensor and lab-on-a-chip devices for point-of-care testing, imaging informatics, and computational analysis and simulation methods.

NATIONAL LIBRARY OF MEDICINE

http://www.nlm.nih.gov NLM searches literature in Pub Med, Medline, and ClinicalTrials.gov, provides decision support, and conducts video conferencing sessions. The Office for High Performance Computing and Communi- cations (OHPCC) manages the program and awards contracts. RFP’s are available when issued from the NLM Office of Acquisitions Management.

Internet2 Internet2 and Level 3 Communications, Inc. have agreed to deploy a nationwide network and services to enhance and support the advanced needs of the academic and research community. This network initially will offer Internet2 members 100 gigabits per second of capacity which is more than 10 times the current Internet2 backbone network. The network supports a full range of production IP services as well as new on-demand dedicated optical wavelength services to enable the most demanding network applications and experimentation.

Disaster Information Management Research Center http://disasterinfo.nlm.nih.gov The DIMRC provides the collection and dissemination of health information for natural, accidental, or deliberate disasters. NLM has a web resource to provide access to quality disaster health information to the nation at all stages of preparedness, response, mitigation, and recovery. The initial phase of the web site focuses on NLM and NLM supported resources and activities but will expand to include other sources of disaster health information.

Women’s Health Research Information http://sis.nlm.nih.gov/outreach/womenshealthoverview.html A web resource now provides consumers with the latest on women’s health research. The Division of Specialized Information Services, Office of Outreach and Special Populations has partnered with the NIH Office of Research on Women’s Health. The web site provides information from scientific journals and other peer-reviewed sources. 27 Federal Activities in Telemedicine, Telehealth, and Health Technology

Newborn Screening Coding and Terminology Guide http://newbornscreeningcodes.nlm.nih.gov NLM has launched the Newborn Screening Coding and Terminology guide to enable the electronic exchange of standard new born screening data. The web site was created in collaboration with the Office of the National Coordinator for HIT, HRSA, CDC, as well as with a number of professional organizations.

Extramural Programs Division http://www.nlm.nih.gov/ep/extramural.html The Division supports grants on medical informatics research, health information sciences, biotechnology information, computer and communications systems in health institutions, plus grants to provide for the development of high-speed computer networks. Up to now, the Division has maintained a searchable database called CRISP with information on funding opportunities and awards on data related to telehealth, telemedicine, and health IT plus other specialties related to the healthcare field. The database contained information on federally funded biomedical research projects conducted at universities, hospitals, and other research institutions. However, in 2009, a new tool was released called the Research Portfolio Online Reporting tool Expenditures and Results (RePORTER) that replaced CRISP but retains all of the CRISP features and provides additional query fields and lists that can be sorted and downloaded to Excel. The system provides links to PubMed Central, PubMed, and the U.S. Patent & Trademark Office.

Grants Resource Support for Information Management has several grant programs related to telehealth, telemedicine, health IT and includes:

• Applied Informatics Grants are available to health-related and scientific organizations that want to optimize the use of clinical and research information, and exploit the capabilities of information technology. In April 2009, a funding opportunity was announced. • Internet Access to Digital Libraries (IADL) grants enable organizations to offer health related information provided by NLM and others to transfer files and images, use e-mail and do video conferencing with colleagues throughout the world. Public and private nonprofit health related organizations are eligible to apply. These grants can be for one or two years, and the base amount is $45,000 with additional funds available for multiple site proposals • Integrated Advanced Information Management System Grants (IAMS) link and relate library systems with a variety of individual and institutional databases and information files. These computer networks are used for patient care, research, education, and administration. Emphasis is on organization-wide and trans-organizational mechanisms that enable the easy flow of information. This includes the exchange of information between healthcare and education institutions, or between health related organizations, such as a community clinic to a hospital or public health department. • Information System Grants are offered to improve and foster the use of computer and telecommunications technologies to coordinate and disseminate health information 28 Federal Activities in Telemedicine, Telehealth, and Health Technology

NLM Support for Research and Development Research and Development grants include:

• Short Project Grants are short term awards designed to support basic and clinical research, to answer specific target research questions, or to perform feasibility testing in biomedical informatics or bioinformatics. The grants provide up to $50,000 per year for one or two years • Exploratory and Developmental Grants support the early and conceptual stages of innovative research projects in biomedical informatics, biotechnology information, and health sciences library and information science. The purpose is to develop projects that have the potential to advance informatics research • SBIR Grants support management and communication of medical or health information and knowledge, including the development, transmission, dissemination, and evaluation of information. • NLM Grants are awarded for informatics for disaster management research projects, developing innovations in biomedical computational science and technology, and for the Small Grant Program.

Office of Extramural Research The Office has posted a web site (http://grants.nih.gov/grants/natural_disasters.htm) to be a resource for the biomedical research community to help the people with health issues in affected disaster areas. NIH in coordination with HHS, OMB, FEMA, and other agencies provide information for the site.

Human Genome Resources http://www.ncbi.nlm.nih.gov/genome/guide/human Human Genome Resources has databases with genetic information to give an overview of available human genome data resources including bulletins and progress reports.

Lister Hill National Center for Biomedical Communications http://www.lhncbc.nlm.nih.gov/lhc NLM’s Lister Hill National Center for Biomedical Communications (LHNCBC) supports research and development in high quality imagery, medical language processing, provides high-speed access to biomedical information, provides for intelligent database systems development, multimedia visualization, knowledge management, data mining, and machine assisted indexing. Researchers are developing technologies to provide easy access to biomedical information using PDAs, wireless portable computers, mobile phones, and other emerging devices. PubMed for Handhelds explores hand-held technology for use in the clinical setting. Wireless PDAs are used in the Biomedical Informatics and Pathology Departments at the Uniformed Services University to provide access to PubMed, MEDLINE, and other NLM databases during small medical student group discussions. Another project called ASKLEPiOS is exploring integrating portable wireless hand-held devices together with non-mobile computer servers and telephones. 29 Federal Activities in Telemedicine, Telehealth, and Health Technology

In another project, the virtual microscope project team has developed a web-based system to enable the user to view an image in an interactive manner simulating the experience of examining a slide under a microscope. Potential applications of the tool include medical education, doing quality control and diagnostic proficiency surveys, and to use for telemedicine applications. Consumer health informatics research focuses on understanding and improving access to online health information. Technologies are being developed to measure text difficulty to help determine the suitability of health related documents for consumers at different literacy levels. The Visible Human Project (VHP) has developed the Insight Toolkit (ITK), a research and development initiative, and has completed several software releases. Additional awards have been made to develop database management tools, workbenches for tumor volume measurement, and web portals for sharing research data and publications.

National Center for Biotechnology Information http://www.ncbi.nih.gov NCBI has a number of biomedical databases and software to coordinate biotechnology information worldwide and links between new and existing databases. The Center is developing innovative computer solutions, disseminating genome information, and training the next generation of interdisciplinary scientists. With the release of the working draft of the human genome, the global research focus is turning from analysis of specific genes or gene regions to whole genomes, which refers to all of the genes found in cells and tissues. To accommodate this shift in research focus, NCBI has developed resources to support the comprehensive analysis of the human genome and is a key component of the NIH Human Genome Project One of the principal resources is the GenBank database, a publicly available annotated collection of all known DNA sequences. The NCBI is responsible for all phases of GenBank production, support, and distribution, including timely and accurate processing of sequence records, and is doing a biological review of both new sequence entries and updates to existing entries. NCBI launched a GWA database called dbGaP to provide a central location for archiving and distributing phenotype and genotype data from a variety of studies ranging from heart disease, women’s health, and diabetes, to environmental factors in disease. NCBI with the Genetic Alliance has launched a web site to help patients, caregivers, and health professionals navigate the vast array of information on genetic disorders. The site links to a wide range of information from basic descriptions of a disease and its symptoms to the most current scientific research. The site also provides a guide to genetic testing along with directories of geneticists, and information on clinical trials.

National Network of Libraries of Medicine http://www.nnlm.gov NLM directs the National Network of Libraries of Medicine to help health professionals with information. The Network web site (http://nnlm.gov/outreach/community) has information on public libraries and community partners working together to provide health information. The site has information on funding and projects especially for multiple community partnerships to address public health informa- 30 Federal Activities in Telemedicine, Telehealth, and Health Technology

tion needs. One program develops regional showcases or technology forums to discuss how information technology can improve biomedical information. NNLM provides regional funding opportunities and includes a projects database.

Unified Medical Language System NLM directs the Unified Medical Language System (UMLS) project, to promote timely access to up-to-date health information, how to understand the actual meaning of user inquiries, and how to use this knowledge to retrieve and integrate information from machine readable information sources. As an information retrieval tool, the UMLS disseminates a detailed and uniform vocabulary for computerized medical records systems, which may evolve into a standard multipurpose nomenclature for logically integrated health information systems.

NLM Gateway http://gateway.nlm.nih.gov The National Library of Medicine has a number of databases to coordinate the development of new information products and services related to health services research. The NLM Gateway searches through the NLM resources and provides a single access point for information. Databases include:

• MEDLINE-database with over 14 million references to journal articles. Each year 500,000 new reports are added • MEDLINE PLUS-site for up-to-date and totally private consumer health information. Includes 600 health topics available to the public on information available from NIH institutes • MEDLINE PubMed-provides access to MEDLINE and includes state of the art retrieval features. Links to 4,000 of the journals represented in MEDLINE. CAM on PubMed provides access to citations from the MEDLINE database regarding complementary and alternative medicine. An extension of PubMed known as PubMed Central is a digital archive of life sciences journal literature created by NLMs National Center for Biotech- nology Information • WISER a PDA Application assists first responders during hazardous materials incidents • Tox Town is an interactive guide to potentially toxic substances and environmental health issues. Household Data Products has information on the potential health effects of chemicals for over 5,000 common household products • HSTAT is a free full text electronic resource for clinical practice guideline and has a searchable collection of full text clinical practice guidelines technology assessments • TOXNET-information on the effects of drugs and other chemicals on humans and contains the Hazardous Substance Data Bank and ChemlDplus • TOXMAP has Toxic Release Inventory data with links to other TOSNET resources • LOCATORplus is NLM’s Catalog of books, audio visuals, and journals • DIRLINE has information on a wide variety of information resources including research projects and databases concerned with health and biomedicine 31 Federal Activities in Telemedicine, Telehealth, and Health Technology

• HSRProj helps locate research-in-progress that is funded by federal and foundation grants and provides research records for health services and health technology assessments • NLM Gateway provides a single access point for the multiple information resources of NLM.

Other web sites have been established to provide health information. One site at (http://health.nih. gov) offers links to a wider range of NIH resources and gives a popular “A to Z” listing of health topics. Another site provides ready access to information on technologies that can help provide higher quality care for the elderly and the disabled.

American Indian Health http://americanindianhealth.nlm.nih.gov NLM has established a web site to address the health concerns of the four million Americans who claim American Indian or Alaska Native ancestry. Research shows that Native Americans are 2.6 times more likely to have diabetes as non Hispanic whites of a similar age. American Indians also have a greater mortality risk for tuberculosis, suicide, pneumonia, alcoholism, and influenza than the average population.

Refugee Health Information Network http://rhin.edu RHIN is a national collaborative partnership sponsored by NLM that created a database of quality multilingual public health resources for care givers to use to resettled refugees and health consumers. RHIN provides links to existing sites specializing in refugee health, offers a variety of posted documents from healthcare providers, and provides medical information.

Clinical Trials http://www.ClinicalTrials.gov NIH, NLM and FDA established the Clinical Trials site to provide links to clinical studies sponsored by NIH, other federal agencies, and the pharmaceutical industry in over 75,000 locations worldwide, including contact information for lead investigators. Studies listed in the database are conducted primarily in the U.S. and Canada, but include locations in about 70 countries. The site receives over two million page views per month and hosts approximately 5,600 visitors daily. Several clinical trials sponsored by the Department of Veterans Affairs involve telehealth and telemedicine. One trial “Evaluating Telehealth Home Care for Elderly Veterans with Congestive Heart Fail- ure” studied how to use advanced telecommunications technologies to improve access and availability of services to CHF patients in their homes. Another trial “Effect of Telemedicine on Physician Patient Com- munication” looked at whether the physical separation between patient and physician required during telemedicine has an effect on physician patient communications and outcomes. The VA is also conducting a clinical trial on “Health Services Implications of a Teledermatology Consult System” to compare consultations performed by teledermatology with usual care dermatology consultations. 32 Federal Activities in Telemedicine, Telehealth, and Health Technology

National Cancer Institute http://www.cancer.gov NCI provides up-to-date accurate cancer information to physicians by developing computerized information systems. NCI provides publications, NCI news, and information on open clinical trials, information on closed clinical trials, plus selected information from the Journal of the National Cancer Insti- tute. Directories contain information on physicians, genetic counselors, and organizations that provide cancer care including FDA approved mammography-screening facilities.

International Cancer Research Portfolio http://www.cancerportfolio.org NCI researchers have an on line database called the International Cancer Research Portfolio to provide instant access to information on ongoing cancer research supported by cancer funding organizations in the U.S. and the UK. The database provides information on the funding organization, awardee institution, principal investigator, and a detailed abstract of the research. Ongoing research is now available in one international web site.

Cancer Biology Program Division of Cancer Biology http://dcb.nci.nih.gov The integrative Cancer Biology Program is gaining new insights into the development and progression of cancer through a systems-wide approach. The initiative funds nine integrative biology centers. The program is incorporating a spectrum of new technologies such as genomics, proteomics, and molecular imaging to use to generate computer and mathematical models to predict cancer progress.

Collaborative Efforts NCI and the National Human Genome Research Institute have committed $50 million over three years to the Cancer Genome Atlas (TCCA) Pilot Project to develop and test the science and technology framework needed to identify and characterize genetic mutations and other genomic changes associated with cancer.

FDA and NCI Efforts The FDA-NCI Task Force is exploring sharing information technologies and tools to further optimize the drug and device development process. The Task Force’s working subgroup is examining of creating an overarching and inclusive bioinformatics structure capable of capturing and integrating data from pre-clinical, pre-approval, and post-approval research across all the sectors involved in the cancer and drug development and delivery progress. FDA and NCI are developing clinical trial management software to make it easier for cancer research groups and the FDA to work collaboratively. As a first step, NCI and FDA will work together on tools to facilitate electronic interactions. The initiative will link cancer researchers around the U.S. 33 Federal Activities in Telemedicine, Telehealth, and Health Technology

electronically to the FDA, thereby reducing the time it takes for promising new drugs to be reviewed for testing in clinical trials.

Cancer Biomedical Informatics Grid https://cabig.nci.nih.gov NCI’s Cancer Biomedical Informatics Grid (caBIG) connects teams of cancer investigators and data and tools to help redefine how cancer research is conducted and how best to provide cancer care. The network goals are to accelerate progress in all aspects of cancer research, cancer prevention, early detection, and treatment, and bring together 50 NCI designated cancer centers. All caBIG activities are open source, open access, and based on common standards. There are more than 43 major cancer centers working on caBIG projects. Over a dozen community cancer centers are working toward interoperable electronic health records to enable information exchange with caBIG compatible tools. Since it began, the program has delivered over 40 products to the community. Building on the informatics foundation of caBIG, a tool called caMatch is being developed to enable patients or their healthcare providers to locate clinical trials that may help the patient. An online version of the tool is currently available as (www.BreastCancerTrials.org). A patient completes an online personal health record which is matched against ongoing clinical trials in the San Francisco and Sacramento areas. An interoperable middleware tool will take data from a PHR and match it against trials in a database. The NCI CBIIT is augmenting traditional support with the caBIG Enterprise Support Network to provide new opportunities for cancer and academic medical centers. The network will offer service providers, knowledge centers, program offices, and enterprise adopters. This will provide for additional ongoing tool development, adoption, and workspace participation.

Office of Technology and Industrial Relations http://otir.cancer.gov OTIR is the access point for private technology developers into NCI. Programs include the Alliance for Nanotechnology in Cancer, Clinical Proteomic Technologies Initiative, and the Innovative Molecular Analysis Technologies program. OTIR plays a key role in managing the Unconventional Innovations Program, bioengineering and bioinformatics initiatives, and SBIR/STTR. Industry partners and NCI work together using several mechanisms. Some of the common agreement types include Cooperative Research and Development Agreements, Clinical Trial agreements, Confidential Disclosure Agreements, Material Transfer Agreements, and licensing agreements. The Office encourages new technologies and collaborations between NCI and the private sector. Currently, there are partnership arrangements between NCI and industry that include:

• The Diagnostic Imaging Network, a multi-institutional team of scientists are evaluating and developing a new generation of imaging concepts and tools with manufacturers and other technology developers • A national clinical trials network for imaging with a peer-reviewed grant program works with industry on clinical assessments and validating emerging technologies • The Phased Innovation Award and its SBIR counterpart provide a grant mechanism, to support exploratory studies of new modalities 34 Federal Activities in Telemedicine, Telehealth, and Health Technology

• The Unconventional Innovations Program supports the development of integrated detection and delivery systems. The program is developing imaging systems by incorporating molecular sensing nanoscale devices and micro explorers that will eventually enable the remote sensing of cancer • NCI and CDC are collaborating on a federally integrated cancer surveillance and cancer control research system. This joint effort will permit coordination of training, technology assistance, methodology development, and other aspects of cancer registry management, as well as allow for the coordination of major cancer information • NCI is expanding the Rapid Access Intervention Development Program to include diagnostic imaging probes, as well as support clinical trials to study new diagnostic probes and devices.

Informatics Initiatives NCI has implemented several informatics initiatives:

• Funding for four Centers of Excellence at the University of Michigan, University of Penn- sylvania, St. Louis University, and the University of Wisconsin for cancer communications research to develop new interactive health communication systems • Establishing the NCI’s Center for Bioinformatics to provide standardized bioinformatics support and integration of research initiatives • Establishing a clinical trials infrastructure to increase information sharing among many clinical trials and other research efforts • Establishing the Cancer Genome Anatomy Project to integrate cancer genetics information • Establishing the Mouse Models of Human Cancer Consortium informatics efforts to provide critical information and tools to researchers • Launched a three year pilot phase of a program called the National Cancer Institute Com- munity Cancer Centers Program to bring state-of-the-art cancer care to patients in community hospitals across the U.S.

Center for Information Technology http://www.cit.nih.gov NCI and NIH’s Center for Information Technology developed the telemedicine system called TELESYNERGY a medical consultation work station. The system is a multimedia, medical imaging workstation used in an electronic imaging environment that allows remote consultations and education between geographically distributed medical specialists of all types. Doubling as a platform for NCI’s Net Trials “TM Clinical Trials Information System”, the system lets Phase I and Phase II research conducted outside the walls of NCI to be directly entered into the NCI research database. As this system develops, other applications will include general cardiology, cardiac and fetal ultrasound, nuclear medicine, otolaryngology, ophthalmology, dermatology, and mammography. The NCI Cancer Consortium established with cancer physicians in Ireland, Northern Ireland, and the U.S. is improving the infrastructure for cancer research and cancer care across Ireland using the TELESYNERGY system to provide video conferencing links between St. Luke’s and St. James’s Hos- 35 Federal Activities in Telemedicine, Telehealth, and Health Technology

pitals in Dublin and oncology centers across Ireland. The system also transmits high quality diagnostic radiology and pathology images.

Multimedia Technology Health Communication Grants NCI has a program within the Division of Cancer Control and Population Sciences using multimedia technology to translate cancer research into programs, interventions, systems, networks, or products needed by the public or primary care professionals, to reduce cancer risk, and to improve the quality of life for cancer survivors. The projects uses a variety of media technology including computer applications, expert systems, advanced telephone technologies, television, videotext, virtual reality, the web, and wireless technologies in nine research categories.

Cancer Nanotechnology Platform Partnerships http://nano.cancer.gov NCI has funded a five-year initiative for nanotechnology in cancer research. Awards totaling $35 million over five years, with $7 million total in the first year, will establish 12 Cancer Nanotechnology Platform Partnerships. The NCI Alliance for Nanotechnology in Cancer has four major program components designed to develop technologies for new products in key programmatic areas.

National Institute of Mental Health http://www.nimh.nih.gov

Office of Rural Mental Health The Office of Rural Mental Health Research (ORMHR) supports grants to study mental health problems and the risks associated with rural life. NIMH funds research to provide access to mental health care for people living in rural and frontier areas, and to provide sensitive high quality mental healthcare on Indian reservations. ORMHR funds telepsychiatry research grants to stimulate research and set up demonstration projects in rural areas with both non-profit and for-profit organizations. The Office on Neuroinformatics coordinates and provides leadership to the interagency Human Brain Project. The office supports investigator-initiated neuroinformatics research and cross- training grant funding opportunities to lead to new digital and electronic tools for all domains of brain and behavioral research. By using sophisticated powerful computational resources, the approaches and technologies being studied are used to generate information that is general, scalable, and interoperable. NIMH and the National Institute on Drug Abuse are studying models of care to deliver mental health services to diverse rural and frontier communities. Researchers are looking at diagnosing and delivering care using telecommunications modalities to underserved locations and populations, to the incarcerated, to the hearing impaired, to the elderly in nursing homes, and the homebound. NIMH is testing data collection technologies to study the mental health consequences of disasters. The goal is to develop computerized patient triage and tracking systems, coordinate databases and survivor registries, work on data storage and confidentiality procedures, and make environmental stress and damage assessments to help manage and disseminate mental health relevant information in a disaster situation. 36 Federal Activities in Telemedicine, Telehealth, and Health Technology

National Institute of Neurological Diseases and Stroke http://www.ninds.nih.gov The University of California San Diego (UCSD) Stroke Center received $5 million in a five year grant from NINDS to pioneer new stroke treatments. The grant called the “Specialized Program of Trans- lational Research in Acute Stroke” (SPOTRIAS) supports clinical trials using hypothermia as a method to extend the window of treatment effectiveness from three to six hours following stroke onset. A thrombolytic drug tissue plasminogen activator tPA is only effective for three hours after the onset of a stroke and should not be given if the patient has evidence of bleeding problems. UCSD is investigating contrast enhance ultrasound in a 288 patient clinical trial. The non-invasive test is administered at the bedside to measure obstruction in blood vessels and allows doctors to have immediate feedback to determine if a patient is a candidate for thrombolytic therapy. NINDS is working with Moberg Research Inc. to develop a neonatal EEG monitor that will use accurate analysis methods to detect earlier detection and management of brain injury in the neonatal population. The monitor could help make care decisions, measure treatment success, and enable more widespread monitoring of the brain status in newborns.

Other Projects Surface cooling techniques used to treat stroke patients can cause complications and fail to adequately cool patients; however, catheter technology has been developed to allow intravascular cooling methods to cool the brain. The UCSD Stroke Center, UCSD Jacobs School of Engineering, and the California Institute for Telecommunications and Information Technology are conducting a clinical trial using broadband wireless technology to send live video to a wireless laptop computer operated by the on-call member of the UCSD stroke team. The team specialist participates in the physical exam, consults with the community physician, and gives advice on the appropriate drugs to use.

National Institute of Allergy and Infectious Diseases http://www.niaid.nih.gov NIAID funded the “Influenza Virus Genome Sequencing Project” that contains the entire genetic blueprints of more than 2,000 human and avian influenza viruses taken from samples around the world with the sequenced data available in a public database. The database is managed by the Institute for Ge- nomic Research. Grants over five years have established eleven “Excellence for Biodefense and Emerging Infectious Diseases Research” regional centers. In 2009, NIAID announced renewed funding for the previously established centers. NIAID has announced that four year grants totaling $80 million would provide funding for two new regional Centers at the University of California, Irvine, and Colorado State University. The centers support vaccine research, training in biodefense research, maintains and supports resources, and provides scientific support to first responders. Centers of Excellence for Influenza Research and Sur- veillance were started. Researchers are looking at how viruses cause disease and how the human immune system responds to infections. Funds have also been awarded to Oregon Health & Science University to establish a Center to be based in the Pacific Northwest. The funding for the centers will be $455 million over five years. 37 Federal Activities in Telemedicine, Telehealth, and Health Technology

National Institute of Child Health and Human Development http://www.nichd.nih.gov Saint Louis University School of Public Health received $26 million for five years from the NICH- HD along with other federal agencies including NIEHA, CDC, and EPA to perform the largest study of child and human health ever conducted in the U.S. The cost for doing the research for the study are children is estimated at $3 billion over the next 25 years. The research for “National Children’s Study” will look at the health and develop of children by following them from before birth to age 21 and look at ways to prevent and treat autism, birth defects, diabetes, heart disease, and obesity.

National Human Genome Research Institute http://www.genome.gov NHGRI is leading the Genes, Environment and Health Initiative (GEI) to identify genetic risks. Researchers use rapidly evolving technologies used in genome-wide association studies to focus on common conditions. The genetic component of GEI relies on the ability to identify genetic difference throughout the genome between people with an illness and healthy individuals. The environmental component will develop new technologies to measure exposures by using small wearable sensors. NHGRI has awarded grants totaling $31 million over four years to do research aimed at gaining a better understanding how specific genetic variants act to influence the risk of diabetes, heart disease, cancer, and other common diseases. NHGRI’s web site provides a reliable source of genomic information for individuals with genetic disorders and their families, teachers and students, and the general public. NHGRI has established a Ge- netic and Rare Diseases Information Center to provide individuals with information. NHGRI has a web-based resource enabling researchers, health professionals to locate information on laws and policies related to a wide array of genetic issues. The focus is on genetic testing and counseling, insurance and employment discrimination, newborn screening, privacy of genetic information and confidentiality, informed consent, commercialization, and patenting. NHGRI has launched an online Spanish Talking Glossary of Genetics to provide a resource for Spanish speaking people seeking a better understanding of recent advances in genetics and genomics. The glossary combines text, illustrations, and audio commentary in an accessible user friendly format. Scientists are researching new methods for early detection of diseases, developing new technologies to sequence the genome of any person, new tools to discover hereditary contributions to common diseases, using chemical genomics technologies to understand biological pathways, and accelerating drug discoveries. NHGRI initiatives include:

• Creation of a Human Haplotype Map to enable scientists to find the genes that affect common diseases • Working on the ENCODE Project a comprehensive encyclopedia of all functional elements to enable scientists to use the information that the human genome sequence contains • Investing in genome technology development to sequence any individuals genome plus pursuing other technology developments that are ripe for expansion • A nationwide Chemical Genomics Network Initiative has been established, with up to ten 38 Federal Activities in Telemedicine, Telehealth, and Health Technology

pilot centers to be funded at academic institutions and other locations across the country. These chemical genomics centers will be coordinated to build a network in the academic research community to identify a broad range of small molecules with promising properties for biological research • Centers have been established in North Carolina and Pennsylvania to focus on genomic research

NIH established the NIH Intramural Center for Genomics and Health Disparities within the NIH Of- fice of Intramural Research. This Center is administered by NHGRI. Additional support will come from the NIH Office of the Director, NIDDK, and the Center for Information Technology.

National Institute of Nursing Research http://www.ninr.nih.gov NINR supports clinical and basic research on the care of individuals across their life span. NINR looks at patient care from the management of patients during illness and recovery, the reduction of risks for disease and disability, and the promotion of healthy lifestyles. NINR supports grants to universities and other research organizations. Some of the projects include:

• Studying genetic advances including the factors that increase the risk of disease issues related to genetic screening and subsequent gene therapy techniques • Using new technologies in lung transplant patients by using a spirometer-monitoring device to transmit daily information on pulmonary function, vital signs and symptoms, to remote locations • Studying the quality of patient care and reduced health care costs using a transitional care model in multiple patient populations

NINR is looking at rapidly evolving telehealth and internet technologies and studying ways to integrate these technologies into practice and training. Research includes:

• Exploring both basic science interventions and clinical applications within the context of nursing science • Investigating effective use of biotechnologies and bioinformatics to provide for new advances to improve self-management, healthy behaviors, and caregivers activities • Managing the incorporation of telehealth into nursing interventions to measure benefits, costs, and patient and clinician satisfaction • Developing and testing creative ways to provide patient education

Grant Program A grant program “Telehealth Interventions to Improve Clinical Nursing Care” is looking at how to stimulate innovative nursing telehealth interventions research particularly among a variety of clinical situations, diverse patient populations, and in different clinical settings. 39 Federal Activities in Telemedicine, Telehealth, and Health Technology

National Institute for General Medicine Science http://www.nigms.nih.gov

Research Centers NIGMS in the Center for Bioinformatics and Computational Biology is working to join biology with computer sciences, engineering, mathematics, and physics. Researchers are developing bioinformatics tools to analyze and store data. NIGMS has established Centers of Excellence in Complex Biomedical Systems Research, and anticipates spending $25.5 million over five years. The centers support multi-investigator teams addressing biomedical complexity through research, training, workshops, symposia, and other forms of outreach. The awards permit a larger scope of activity than would be possible via research grants to individual investigators. Two awards totaling $4.5 million were made to the University of Washington and Case Western Reserve University. Other future centers will be at Boston University, University of California (Irvine) and the University of New Mexico. NIGMS and other components of NIH are sponsoring research to understand how a person’s genetic makeup determines how medicine works in the body as well as the side effects. This research called phar- macogenetics focuses on linking the body’s response to medicines with variations in particular genes.

Computer Aided Drug Design NIGMS has funded millions to advance computer aided drug design. The idea is to expand and enhance molecular data needed to develop computer programs to more accurately predict potential drug candidates.

Collaborative Effort NIGMS and the Indian Health Service are collaborating on a program to link the Native American community with organizations that conduct health research. The centers called Native American Research Centers for Health encourage research on diseases and on health conditions of American Indians and Alaska nations. The program has American Indian biomedical and behavioral scientists and health professionals competing for NIH funding. Another goal is for research-intensive organizations and Native American organizations to have partnerships to produce competitive research proposals.

MIDAS Initiative An initiative called “Models of Infectious Disease Agent Study” (MIDAS) is developing powerful computer modeling techniques to analyze and respond to infectious disease outbreaks whether they occur naturally, such as SARS, Avian Flu, or are a result of bioterrorism. In 2009, MIDAS awarded grants with a grant going to the University of Pittsburgh to study how to control the spread of infectious diseases. The five year grant is funding the development and testing of computer simulations to ultimately enable public health officials and policymakers to evaluate intervention strategies to contain infectious disease outbreaks. A software program called TransState was developed by a team of epidemiologists and computer scientists collaborating on MIDAS. TransState is used by public health officers at the site of an outbreak 40 Federal Activities in Telemedicine, Telehealth, and Health Technology

to systematically enter and store data. The computer program statistically determines the probability that people contracted the disease from each other.

Advisory Council The National Advisory General Medical Sciences Council is composed of leaders in biological and medical sciences, education, healthcare, and public affairs. The Council makes recommendations on policy and program development, implementation, and evaluation.

National Institute on Aging http://www.nia.nih.gov The National Institute on Aging awarded a five year $7 million Bioengineering Research Partner- ship (BRP) grant to the Oregon Health & Science University, Oregon Center for Aging and Technology or ORCATECH. The BRPs are multidisciplinary research teams bringing together bioengineering experts with basic and clinical investigators to study and develop methods for preventing, detecting, diagnosing, and treating diseases. The funding enables ORACATECH to develop and test technologies to establish a large network of monitored elder-inhabited homes. Each home is outfitted with a basic set of devices for continuous, remote assessment of activity so that fluctuations can be reported that may indicate problems with cogni- tion and mobility. These devices include motion and door sensors to track walking, and overall in-home activity, along with computers that are outfitted with software that can detect patterns that can indicate memory changes. The Institute is working on a project with the University of Texas Southwest Medical Center in Dallas to study how to use telemedicine technology to conduct neurocognitive testing. Video conferencing technology is used to help provide long distance assessment for dementia, as compared to traditional face-to-face examinations in older Native American and non Native American adults with or without cognitive impairment. The Institute will develop models to forecast Medicare expenditures and provide insight into cost growth and population aging. Measuring future Medicare expenditures requires more than just understanding factors beyond cost growth and takes into consideration other factors such as disabilities and life expectancy.

National Heart, Lung, and Blood Institute http://www.nhlbi.nih.gov NHLBI has released a Strategic Plan to guide the next decade of research, training, and education to reduce the burden of cardiovascular, lung, blood, and sleep disorders. The plan uses emerging and sophisticated research approaches while adapting to a rapidly changing healthcare environment and flexible to invest in new research.

Genomic Activities NHLBI launched the “Programs for Genomic Applications (PGAs)” with $37 million in grants. This initiative expands data and develops technologies to map and sequence the human genome. The studies 41 Federal Activities in Telemedicine, Telehealth, and Health Technology

link genes to biological function on a genomic scale, provides free and immediate information access to the research community, short term advanced training, plus educational programs on using the data and related technologies. NHLBI has expanded its collection of genetic and clinical data made available to researchers. The expanded information includes clinical and genetic information collected from three asthma research networks. NHLBI has launched a project to identify the genes underlying cardiovascular diseases and other disorders like osteoporosis and diabetes. The project promises to greatly accelerate discoveries regarding the causes and prevention of cardiovascular disease. NHLBI genome-wide association studies and data sharing projects include the Candidate Gene Association Resource Project, the Enhancing Development of Genome Wide Association Methods, Women’s Genome Study, and the Women’s Health Initiative Genomic Studies. SNP Health Association Resource (SHARe) is a web-based dataset to enable qualified researchers to access data from large population-based studies starting with the Framingham Heart Study. SHARe will accelerate discoveries linking genes and health. The expansion of the project is called SHARe- Asthma Resource Project.

Chronic Diseases Worldwide To deal with worldwide chronic diseases, the NHLBI has awarded contracts worth more than $34 million to set up chronic diseases training networks in nine countries to be led by a research institution and paired with an academic institution in the country. Centers will be funded in Bangladesh, china, Gua- temala, India, and South Africa with three additional Centers in Argentina, Kenya, and Peru. The centers will do research tailored to the local or regional needs to reduce the burden of chronic diseases including heart disease, hart failure, stroke, diabetes, and COPD. Related risk factors such as high blood pressure, high cholesterol, obesity, and environmental exposures that contribute to COPD will be emphasized.

Blood Tests to Identify High Risk Individuals In 2009, the Framingham Heart Study (FHS) funded by NHLBI was launched to find risk factors and markers that can lead to new blood tests to identify high risk individuals for heart disease and stroke. A public-private partnership was established to enable researchers to apply cutting-edge technology to stored blood samples from thousands of FHS participants. FHS is collaborating on the research with Boston University School of Medicine and the School of Public Health.

Cardiovascular Research Grid NHLBI has approved a $7.5 million grant to be allocated over a five year period. The project is based at the Institute for Computational Medicine at Johns Hopkins University in collaboration with the Department of Biomedical Informatics at Ohio State University, and the College of Medicine and the Center for Research in Biological Systems at the University of California, San Diego. The Grid will assemble large research teams and experts to focus on common problems and share data with computational scientists. 42 Federal Activities in Telemedicine, Telehealth, and Health Technology

Addressing Heart Attacks and Problems NLM along with support from the NHLB’s National Heart Attack Alert Program is funding a number of projects that use medical informatics techniques to help heart specialists’ deal effectively with the so called “golden hour” immediately after a heart attack. The program eventually will include the creation of a National Emergency Medicine Extranet to improve heart attack care. Johns Hopkins Medical Institution and the Johns Hopkins University Applied Physics Laboratory working with NHLBI have developed a card-sized device to be carried by patients with a high risk for developing an acute coronary syndrome. The card is capable of transmitting current, past history, baseline information, and current ECG from any telephone to a central facility. The information is transmitted into an automated decision support system to assign relative risk and then dispatches EMS to the location or sends the call to a chest pain center for review by a physician. Future possibilities will use satellite linkups and enable echocardiograms and 12 lead EKGs to be transmitted 24/7. The system will continuously monitor biosensors, radiation, and pollution detection devices. The Institute is doing research on new approaches, tools, systems, devices and bioengineering-based methods to use to monitor resuscitations. The goal is to reduce morbidity and mortality from those people that collapse from circulatory hypoxemic or traumatic arrest. In 2009, NHLBI was awarded $566,000 in Recovery Act funding to help Vanderbilt University researchers develop an innovative optical system to study the heart. The funding will enable the research team to purchase a pair of $60,000 high speed and highly sensitive digital cameras to record the changes in the metabolic and electrical activity of isolated cardiac tissue.

National Eye Institute http://www.nei.nih.gov The National Eye Institute (NEI) has published the “National Plan for Eye and Vision Research” to provide information on vision research and identify the most pressing scientific needs and opportunities. According to the plan, technologies for low vision enhancement have continued to improve with new ways for people with visual impairments to get around using visual, auditory, and haptic cues from the environment. Progress has been made in leveraging mainstream technologies to help the visually impaired by improving text-to-speech and speech-to text software programs, plus providing magnified text on most computers. New embossing technologies produce tactile cues that give people better access to graphics. There has been progress in developing global positioning system-based navigation, talking signs, auditory signals at street crossings, and bar coding schemes for labeling locations and objects. Portable assistive devices that enhance residual vision also represent important gains, and progress has been made in the development of assistive intraocular aids, such as the implantable monocular telescope. The Low Vision and Blindness Rehabilitation Panel recommends leveraging and adapting mainstream technologies such as microelectronics, navigation and location aids, haptic technologies, and encourages the development of software for separating content from display format. The panel wants to see more research on imaging technologies. NEI and NASA have worked together to develop a simple, safe eye test for measuring a protein related to cataract formation. If subtle protein changes can be detected before a cataract develops, people may be able to reduce their cataract risk by making simple lifestyle changes. NEI and NASA have de- 43 Federal Activities in Telemedicine, Telehealth, and Health Technology

veloped a device that can detect the earliest damage to lens proteins that can trigger an early warning for cataract formation and blindness.

National Institute of Environmental Health Sciences http://www.niehs.nih.gov The Institute is funding grants to develop new technologies to improve the measurement of environmental exposures that contribute to human diseases. The funding will develop portable easy to use sensing devices that will accurately measure personal exposure to a wide variety of chemical and biological agents. NIEHS is funding three research centers called “Disease Investigation Through Specialized Clini- cally Oriented Ventures in Environmental Research (DISCOVER)”. The centers will help to define the role of environmental agents in the initiation and progression of human disease and develop new ways to prevent and treat disease The National Science Foundation and NIEHS funded four joint Centers for Oceans and Human Health. The centers located at the University of Washington, the University of Hawaii, the Woods Hole Oceanographic Institution, and the University of Miami, have experts in biomedical and oceanographic sciences studying harmful alga blooms, marine pathogens, and the oceans vast potential for drug discovery. Oceans present a diverse array of organisms that show promise for new drugs to fight cancer and fight infectious diseases.

National Institute of Dental and Craniofacial Research http://www.nidcr.nih.gov Scientists supported by NIDCR have engineered a fully automated all-in-one test called “lab on a chip” that can be programmed to probe cells brushed from the mouth for a common sign of oral cancer. The portable device yields results in less than 10 minutes. The test measures the level of EGFR on three distinct types of oral cancer cells. In 2009, NIDCR issued eleven research and technology grants for the new FaceBase Consortium. The five year initiative will systematically compile the biological instructions to construct the middle region of the human face and define the genetics underlying common developmental disorders.

National Institute on Drug Abuse http://www.nida.nih.gov NIDA provides data management and statistical analysis services to support multi-site clinical trials conducted within the Institute’s Clinical Trials Networks. The trial studies include behavior, pharmaco- logical, and integrated therapies in community-based treatment programs. In 2009, NIDA introduced the first Physicians Outreach Initiative called NIDAMED that enables medical professionals to use tools and resources to screen their patients for tobacco, alcohol, illicit and nonmedical prescription drug use. The tools include online screening, a reference guide and a comprehensive resource guide for clinicians. 44 Federal Activities in Telemedicine, Telehealth, and Health Technology

National Center on Minority Health and Health Disparities http://www.ncmhd.nih.gov The University of Illinois at Chicago has been awarded a $7.2 million grant to establish the UIC Center of Excellence in Eliminating Health Disparities. The center is funded by the NCMHD to focus on health disparities in prostate and colorectal cancer, community-based breast cancer initiatives, training, and educating the next generation of health disparities researchers.

National Center for Research Resources http://www.ncrr.nih.gov The NCRR divisions are working on biomedical technology research and resources, clinical research resources, comparative medicine, and research infrastructure. NCRR provides funding for High- End Instrumentation grants to develop cutting edge equipment needed to advance biomedical research.

Centers for Interdisciplinary Research http://www.ncrr.nih.gov/biomedical_technology/ interdisciplinary_research_centers NCRR is leading the Clinical and Translational Science Awards (CTSA) to fund diverse, clinical and translational far-reaching approaches related to all aspects of research. The goal is to use health and research information technology to increase the understanding of disease, facilitate clinical studies and trials, and advance adoption of effective treatment. Investigators are focusing on cancer, diabetes, renal disease, infant mortality, HIV/AIDS, and cardiovascular diseases. The Centers will receive $533 million over 5 years and much of the funding will come from termi- nating grants to General Clinical Research Centers supplemented by NIH Roadmap funds. In 2012 when the program is fully implemented, approximately 60 CTSAs will be connected with an annual budget of $500 million. In 2009, NIH awarded three contracts for pilot projects to improve informatics support for researchers doing small to medium-sized clinical studies. The projects to be administered by NCRR with two year contracts total $4 million. The funding will help advance collaborations in clinical and translational research by using interdisciplinary teams of investigators.

Division of Biomedical Technology Research and Research Resources http://www.ncrr.nih.gov/biomedical_technology The Division supports the Biomedical Technology Resource Centers Program with five-year competitive grants, and supports specialized centers located nationwide primarily at academic and other research institutions. These centers provide a broad spectrum of technologies, techniques, and methodologies to the biomedical research community. Grants are available to acquire advanced instrumentation, for technology research and development, and to provide small business opportunities. The Biomedical Technology Resource Center at Brigham and Women’s Hospital in Boston Massachusetts received a grant from NCRR to develop Multi-Isotope Imaging Mass Spectrometry (MIMS). 45 Federal Activities in Telemedicine, Telehealth, and Health Technology

Division of Clinical Research Resources The Division supports resources to use for clinical research and to assure the safety of participants in research. A national network of General Clinical Research Centers provides a range of resources for direct patient research. For example, ten Islet Cell Resource (ICR) Centers isolate, purify, and characterize human pancreatic islets for subsequent transplantation into patients with type 1 diabetes. The Division of Clinical Research supports the ICR Centers and links them electronically to the Administrative and Bioinformatics Coordinating Center.

Division of Comparative Medicine The Division supports a wide range of research, and identifies and develops improved biologic models for the study of human diseases such as AIDS, seizure disorders, Parkinson’s, and Alzheimer’s diseases.

Division of Research Infrastructure The Division provides competitive funding to modernize and construct research laboratories capable of supporting sophisticated research.

Biomedical Informatics Research Network http://www.nbirn.net The Division supports the Biomedical Informatics Research Network (BIRN), a NCRR initiative to create a testbed to help biomedical researchers access and analyze data at diverse sites throughout the country. Although brain imaging technology has generated progress in how mental and neurological diseases develop, it is difficult for one laboratory to share and compare findings with other laboratories. The lack of coordinated networks, limitations in compatible computer hardware, software, and imaging equipment have isolated scientists. This initiative will help develop a large database of brain images. NCRR is providing $32.8 million in additional funding to the BIRN. The University of California Medical School in San Diego will receive $18.8 million over five years, while the Massachusetts General Hospital will be granted $14 million for three years of support. NCRR has provided funds to create an extensive and unique database of brain information that will help researchers understand disabling brain illnesses such as schizophrenia and speed the development of new treatments. A grant was awarded to the joint General Clinical Research Center at the University of California, San Diego and the University of California, Irvine to coordinate vast amounts of computerized data from brain images of people who have schizophrenia, and create standardized powerful tools for future brain studies in large populations. The scientists will share brain imaging data, including high- resolution MRIs of brain structure and function, advanced 3D microscope images, and related genomic structural and gene expression data. NCRR provides funding for Centers of Biomedical Research Excellence. Awards went to the Loui- siana State University Pennington Biomedical Research Center to study obesity and diabetes, University of Kansas Medical Center to study liver disease, the University of Mississippi to conduct neuroscience research, and to the University of Vermont to examine infectious pathogens. 46 Federal Activities in Telemedicine, Telehealth, and Health Technology

Institutional Development Awards http://www.ncrr.nih.gov/idea Institutional Development Awards (IDeA) support multidisciplinary centers with each center con- centrating on one general area of research. The goal is to strengthen institutional biomedical research capability and enhance research infrastructure. The program serves populations such as rural and medically underserved communities and also supports IDeANet, an internet-based network providing connectivity for high bandwidth science applications. NIH over the next five years will fund IDeA Networks of Biomedical research Excellence in nine IDeA eligible states. The funding will be used to expand research opportunities and to increase the number of competititve investigators in 23 eligible states and Puerto Rico.

Genome Fingerprint Scanning Program NCRR is providing $1 million over three years to the University of North Carolina at Chapel Hill to develop and make available a Genome Fingerprint Scanning program. The tool allows researchers to match mass spectrometry data directly to raw, genetic sequences, to identify proteins, and locate novel genes. Proteomics, the study of how proteins interact and respond to changing conditions in complex systems is being used to decipher diseases such as cancer, diabetes, and Alzheimer’s.

Office of Rare Diseases http://rarediseases.info.nih.gov

Rare Diseases Clinical Research Network Approximately 25 million people in the U.S. are affected by an estimated 6,000 rare diseases or conditions. Because of the small number of affected patients in any one location, rare disease research requires the collaboration of scientists from multiple disciplines to share national research resources. NIH established the Rare Diseases Clinical Research Network with $51 million in grant funding over five years from several NIH components including NCRR, NICHHD, NINDS, NIAMSD, and NIDDKD. The network consists of seven Rare Diseases Clinical Research Centers (RDCRC) and a Data and Technology Coordinating Center (DTCC). The Centers are located at Baylor College of Medicine, Boston University School of Medicine, Children’s Hospital Medical Center in Cincinnati Ohio, Children’s National Medical Center in Washington D.C., Cleveland Clinic Foundation, Weill Medical College, Cornell University, and the University of South Florida in Tampa. The goal is to integrate genetic, micro array, clinical, laboratory, and imaging data. The RDCRCs and their sites work with DTCC in developing common data elements, standards, and data structures, and look for ways to share data and databases. The web site offers over 500 technologies that are available for licensing related to rare diseases or conditions. The technologies listed involve drugs, biologics, and devices that are available to go from NIH and FDA to the private sector for further research and development and potential commercialization. In 2009, NIH launched the first integrated drug development pipeline to produce new treatments for rare and neglected diseases. The $24 million program jumpstarts a trans-NIH initiative. The program created a drug development pipeline within NIH and is specifically intended to stimulate research collabora- 47 Federal Activities in Telemedicine, Telehealth, and Health Technology

tions with academic scientists working on rare illnesses. The Office of Rare Diseases Research oversees the program. In October 2009, the second phase of the Rare Diseases Clinical Research Network announced funds for 19 research consortia was available. The Rare Diseases Clinical Research Consortia and a Data Management Coordinating Center will be awarded $117 million over the next five years.

Undiagnosed Diseases Program http://rarediseases.info.nih.gov/Undiagnosed NIH researchers have launched a clinical research program to find answers for patients with mys- terious conditions that have long eluded diagnosis. The program tackles the most puzzling medical cases and physicians now refer these difficult cases to the NIH Clinical Center. Specialties include endocrinology, immunology, oncology, dermatology, dentistry, cardiology, and genetics.

Research Centers in Minority Institutions Program http://ncmhd.nih.gov RCMI program supports research capacity and infrastructure at minority colleges and universities. The program awarded $15 million to Florida A&M University to increase the biomedical research capacity of the College of Pharmacy and Pharmaceutical Sciences. The grant increases research on drug delivery and neuroscience, provides instrumentation and technical support to help develop new drug therapies, set up a molecular laboratory with state-of-the-art equipment, and established a Center for Health Research and Bioinformatics.

Scientific and Resource Networking The goal is to harness the power of social networking to help scientists and students throughout the country accelerate biomedical research. Over $27 million was awarded to the University of Florida and Harvard University Medical School through ARRA funding. This initiative will bring internet based tools using social networking to biomedical research to enhance interdisciplinary research.

Fogarty International Center http://www.fic.nih.gov In 2009, the Center became the founding member of the Global Alliance for Chronic Diseases and is collaborating with national health agencies in some of the biggest countries in the world. The GACD comprises six world agencies that supply about 80 percent of all public research funding in the world. The Center is also making initial grants in its “Millennium Promise Awards” program to train researchers in chronic diseases. The funding for the first awards was made to train researchers in Asia, Africa, Latin America, and the Middle East. Also, in 2009, the Fogarty International Center (FIC) announced an award of $537,000 over three years to fund international research collaboration at five universities. Each institution will receive funding to increase the access to emerging research techniques and capabilities and support research on a wide range of public health issues. FIC in partnership with the National Institute of Dental and Craniofacial Research funds the 48 Federal Activities in Telemedicine, Telehealth, and Health Technology

“Framework Programs in Global Health” to support promising approaches in global health research, training at universities to use in low and middle income nations and to link multiple schools to advance global health research and training. FIC funds international collaborations to provide informatics training programs such as the “Informatics Training for Global Health” (ITGH) program. FIC already has an “International Training in Medical Informatics Program” that funds projects in the nations of sub- Saharan, Africa, Latin America, and the Caribbean. FIC has released a strategic plan to direct the Center’s activities until 2012. The strategic plan’s first goal is to address the growing epidemic of chronic non-communicable diseases while continuing to address the unfinished infectious diseases agenda. FIC plans to fund $1.5 million per year in a grant program designed to address chronic diseases and build research capacity in areas such as stroke, lung disease, cancer, environmental factors, obesity, lifestyle, and the relationship of genetics to chronic diseases. In 2009, FIC will award more than $9.23 million to eight global health informatics programs over the next five years. The Fogarty Informatics Training for Global Health program is in place to increase informatics expertise in low and middle income countries, to train scientists to design information systems.

NIH SBIR Program http://grants2.nih.gov/grants/funding/sbir.htm The Small Business Innovation and Research (SBIR) program funds research and development that will result in new commercial products. NIH supports the grant mechanism to develop innovative technologies in biomedical and behavioral research. Another program, the Small Business Technology Transfer Research (STTR) program differs somewhat from the SBIR program, as the STTR program does research and works on the commercialization of that research and conducts joint ventures with small businesses working with research institutions. In 2009, NIH and CDC issued a SBIR solicitation to find research proposals to stimulate technology innovation. The National Cancer Institute , The National Institute on Drug Abuse, and NHLBI are looking for ideas to meet Federal R& D needs. NIH helps small organizations find collaborative opportunities related to the SBIR/STTR programs. Visit (http://grants1.nih.gov/grants/funding/corp.htm) to help find partners by submitting organization needs and capabilities. When companies submit information, this information is added to the Collabora- tion Opportunities and Research Partnerships.

Manufacturers Assistance Program The Manufacturers Assistance Program is available at NIH. The program is geared to help SBIR Phase II awardees. The program helps SBIR awardees identify, address, and develop strategies to help overcome manufacturing issues related to the commercialization of their SBIR developed products.

SBIR Commercialization Assistance Program http://grants.nih.gov/grants/funding/cap.htm NIH offers SBIR II awardees the chance to participate in an assistance program that provides indi- vidualized assistance to improve strategic business plans, improve the small company’s market research 49 Federal Activities in Telemedicine, Telehealth, and Health Technology

capabilities, identify potential partners and investors, develop licensing opportunities, establish strategic partnerships, and help with regulatory approvals needed to perform clinical trials. The CAP program is managed through a contract with the Larta Institute of Los Angeles and is free of charge.

SBIR Niche Assessment Program http://grants.nih.gov/grants/funding/map.htm NIH has made the Niche Assessment Program available for Phase 1 SBIR applicants. Foresight Science and Technology under contract to NIH assesses the potential uses for the technology being developed in the program. The contractor produces a specific report for each SBIR awardee on their particular technology. Information is researched on the needs and concerns of end users, competitive advantage of the technology, key competitors, what customers will pay for the technology, what drives the market for the technology, market size, and the potential for customers, licensees, investors, or other possible commercialization partners.

NIH Small Business Office http://www.dhhs.gov/osdbu The Small Business Office serves as an advocate for small business, and conducts seminars on doing business with NIH, provides contract resources, contract data, HHS small business forms, news, policy reviews, and state and local government resources.

Office of Technology Transfer http://ott.od.nih.gov

NIH Pipeline to Partnerships http://www.ott.nih.gov/p2p/index.asp NIH has launched a virtual space for licensees and SBIR/STTR awardees to showcase their technologies and product development to potential strategic partners, investors, and licensees.

Electronic Submission of NIH Grant Proposals The electronic submission of NIH grant proposals is done by:

• First registering with the Central Contractor Registration and obtaining a DUNS number • Registering the authorized organizational representative/signing officer with eRA Com- mons and grants.gov • Preparing an application using the SF424 (R&R) form

Health Resources and Services Administration

http://www.hrsa.gov The 2009 stimulus package provides $2.5 million for HRSA including $500 million for community health centers. In March 2009, $338 million was released to expand services at the health centers and dis- 50 Federal Activities in Telemedicine, Telehealth, and Health Technology

tributed to 1,128 federally qualified health center grantees. The health centers will create or retain 6,400 health center jobs. In October 2009, HRSA allotted 18 grant funding under the Recovery Act for $27.8 million to go to health center controlled networks and to large multi-site health centers to implement electronic health records and other HIT innovations.

Grant Programs HRSA administers the New Start Expansion grants to provide healthcare access in medically underserved areas to 150,000 individuals, with grant amounts varying in size based on the scope of the project and the size of the service area. Funds for the grants come from HRSA’s Consolidated Health Centers program to include the Community Health Centers, Migrant Health Centers, and Health Communities grant programs. HRSA has a grant program to improve the retention of nurses and to enhance patient care. Projects that will substantially benefit rural or underserved populations or help meet public health nursing needs in states or in local health departments, will receive preference. The grants are to increase collaboration and communication among nurses and other healthcare professionals and to promote nurse involvement in the organizational and clinical decision making process. Schools of nursing, nursing centers, academic health centers, healthcare facilities, state or local governments, and other public or private nonprofit entities are eligible for the grants. As part of the Healthy Tomorrows Partnership for Children Program, HRSA funds programs to stimulate innovative community-based programs. The program encourages the use of innovative health IT. HRSA is involved in telehealth grant activities which are not always labeled as telehealth programs or activities, and the goal is to diffuse telehealth into all of HRSA’s programs. The emphasis is on measuring the impact of telehealth technologies. Specifically, OHIT supports a portfolio of telehealth grants including the Telehealth Resource Center Grant Program, the Telehealth Network Grant Program, and the Licensure Portability Grant Program. In October 2009, HRSA made $1.5 million available to fund up to three grant awards supported by ARRA for “Licensure Portability Special ARRA Initiative” grants to help state professional licensing boards carry out programs where licensing boards from various states will be able to cooperate to develop and implement state policies to reduce statutory and regulatory barriers to telemedicine.

Clinical Quality Performance and Improvement Measures HRSA requires core measures to be reported on childhood immunization rates, entry into prenatal care, low birth weight babies, percent of females with pap tests, diabetes control, and high blood pressure.

Infant Audiology Telemedicine Program HRSA is involved in developing a diagnostic and management protocol for using telemedicine to deliver hearing services in rural and underserved areas and to assist with the implementation of the protocol among selected grantees. This is particularly important in rural areas because of the shortage of pediatric audiologists and equipment. 51 Federal Activities in Telemedicine, Telehealth, and Health Technology

Epilepsy and Telehealth HRSA provides funding to support telehealth networks to provide services in different settings. These may include long term care facilities, community health centers or clinics, medical homes, hospitals, and schools. The funding is demonstrating how telehealth networks can be used to expand access and improve the quality of healthcare services in medically underserved and rural areas. The primary goal is to use telehealth technologies to help children and youth with epilepsy and assist their families.

Office of Rural Health Policy http://www.ruralhealth.hrsa.gov HRSA has put improving the quality of rural healthcare high on the agenda. The agency wants to increase funding for Rural Health Care Services Outreach, Network, and Quality Improvement grants.

Rural Task Force To emphasize rural health, the HHS Secretary created the HHS Rural Task Force to examine how HHS programs can be better serve rural communities and reach across all 12 divisions in HHS. The Task Force looks at regulatory and statutory barriers, examines ways to strengthen existing programs and services, and identifies where additional funding may be needed.

The Task Force is improving small rural hospitals, by looking at rural hospital’s access to expert support services and technical advice, and seeking ways to increase the capital needed for upgrading technology, equipment, and facilities. The Task Force has focused on Medicare Advantage in rural communities, Head Start in rural communities, and how substance abuse affects rural residents.

National Advisory Committee on Rural Health and Health Services http://ruralcommittee.hrsa.gov ORHP’s National Advisory Committee on Rural Health and Rural Health Services makes recommendations for rural data needs, new programs and publishes annual reports. A report “Exploring Evalu- ation of Rural Applications of Telemedicine” examined the status of rural telemedicine and developed evaluation tools and methods for agencies and individual programs to use to assess telemedicine in rural healthcare delivery. Another report “Rural Health in the United States” identified healthcare disparities for rural Americans and the need for improved access to quality care.

Rural Information Center Health Services http://www.nal.usda.gov/ric Through an interagency agreement with the Department of Agriculture, ORHP supports a national clearinghouse called the Rural Information Center Health Services (RICHS) to collect and disseminate rural health information. The Center provides customized assistance, information on federal grant programs and the status of legislation. In addition, ORHP works closely with the Department of Agricul- ture’s Cooperative Extension Service. 52 Federal Activities in Telemedicine, Telehealth, and Health Technology

Rural Grant Programs The Office of Rural Health Policy (ORHP) has administered millions in grants for telemedicine, telehealth, and distance learning. ORHP assists the Secretary in developing rural health finance policy, supports rural telemedicine demonstration projects, and advises on Medicare and Medicaid programs that affect rural populations.

State Offices of Rural Health http://ruralhealth.hrsa.gov/funding/sorh.htm The State Offices of Rural Health fund small matching grants in all fifty states, and link small rural communities with state and federal resources.

Flex CAH HIT Grants Flex Critical Access Hospital Health Information Technology Network Implementation (Flex CAH HIT) grants promote the implementation of HIT and EHRs in Critical Access Hospitals. The program provides funds to 16 grantees to develop one Flex CAH HIT Network pilot program in each state that is awarded a grant.

Rural Hospital Flexibility Grant Program The State Rural Hospital Flexibility Grant Program funds two programs focusing on rural hospitals. One program is called the Flex Program and the other program is called the Small Hospital Improvement Program. The Flex Program helps a rural community decide if their local hospital would benefit from conversion to critical access hospital status, and the grants fund networking, quality improvement, and emergency medical service projects for the hospitals. The Small Hospital Improvement Program helps small rural hospitals with 49 beds or less to improve performance and reduce medical errors by providing technical assistance, services, and information technology.

Rural Health Care Services Outreach Grants The Rural Health Care Services Outreach Grant Program supports the direct delivery of healthcare and expanding existing services. Grants are awarded to provide new and innovative models for healthcare delivery through the integration and coordination of local services such as primary medical and dental care, mental health treatment, health promotion, health education, and hospice care. These grants include the Rural Network Development Grants, Rural Network Planning Grants and the Delta Network Devel- opment Grants. The Outreach program in 2008 did not have a competition for awards but funding cycles are now proceeding.

Rural Network Development Grants The Rural Network Development Grant Program enables rural healthcare providers to join together in formal networks to help build a stronger healthcare delivery system. The need for these grants has increased in recent years as providers are working together on contracting with managed care organizations to focus on quality improvement and pharmaceutical assistance programs. 53 Federal Activities in Telemedicine, Telehealth, and Health Technology

Network Development Planning Grants The one year grants help providers focus on developing an integrated healthcare network, and help develop a formal network to improve the coordination of health services in rural communities.

Delta Network Development Grants The Delta Network Development Network Grant Program and the Delta Rural Hospital Improve- ment Project work to improve health in the Mississippi Delta region.

Targeted Rural Health Research Grant Program The Grant Program” support research on several topics such as workforce issues, oral health, and HIT implementation. The areas to be funded include rural health clinics in terms of finance, utilization, and service mix, frontier health services delivery, emergency medical services, leadership, allied health workforce, and public health in terms of finance, HIT, and coordination.

Small Health Care Provider Quality Improvement Grants The grants help rural providers implement quality improvement strategies while improving patient care and chronic disease outcomes. The grants support critical access hospitals and rural health clinics to improve quality in managing chronic diseases in ambulatory care settings. The grants fund a patient registry system and track specific health indicators using nationally accepted clinical measures.

Licensure Portability Grant Program The grant program provides support for State professional licensing boards to carry out programs under which state licensing boards cooperate to develop and implement state policies and systems to reduce statutory and regulatory barriers to telemedicine.

Other Grants Other grants include the Rural Emergency Medical Services Grants, Rural and Community Access to Emergency Devices, Healthy Community Access Programs, National Health Service Corps, AHECs, Health Education Training Centers, plus there are grants awarded in the geriatrics field and for training.

SPECIAL PROJECTS Connections Project Through a cooperative agreement with HRSA, the Public Health Informatics Institute has established several activities to help people with a common interest find solutions to problems. The “Connections” project provides technical assistance to public health agencies as they develop strategies and activities to integrate information systems to improve the health of children. Activities involve screening newborns to provide a blue print for developing IT systems. 54 Federal Activities in Telemedicine, Telehealth, and Health Technology

Regional Genetic and Newborn Screening Service Collaboratives The program has undertaken projects to assess how to integrate clinical and laboratory medical genetics into electronic health systems.

Addressing Health Disparities http://www.healthdisparities.net HRSA in addressing health disparities works with collaboratives to transform primary healthcare practices by eliminating health disparities. Strategic goals include implementing the Care Model and the Model for Improvement in Health Centers, improving community organizational resources and the alignment of community activities, implementing measures to address all health center activities, and helping health centers prepare for the HIT market. A five year grant initiative is being awarded to help community health centers increase access to healthcare for low-income and uninsured Americans. Funds also support programs serving migrant health, healthcare for the homeless and primary healthcare for residents of public housing. The grants will expand medical capacity at existing health centers to help an additional 255,000 underserved individuals receive care. The five year initiative increases the number of health centers by 275 and expands to 303 sites.

Patient Safety and Clinical Pharmacy Collaborative http://www.hrsa.gov/patientsafety/ HRSA started the Collaborative to improve patient safety, increase high quality care, provide cost effective pharmacy services, and improve health outcomes at health centers and among HRSA partners.

Bureau of Health Professions http://bhpr.hrsa.gov The Bureau studies national health professions education and workforce needs for the future of healthcare in the U.S. HRSA is focusing on placing health professionals in medically underserved areas. The agency is expanding loan repayment and scholarship programs for physicians, nurses, and dentists who practice in medically underserved areas. There are four advisory committees that includes the Council on Graduate Medical Education, the Advisory Committee on Training in Primary Care Medicine and Dentistry, Advisory Committee on Interdisciplinary Community-based linkages, and the National Advisory Council on Nurse Education and Practice. The Bureau has established a Health Workforce Information Center to provide information on one centralized and easy to access online location to help develop strategies to meet workforce demands.

Office of Health Information Technology http://www.hrsa.gov/healthit/ict.htm HRSA established the Office of Health Information Technology to integrate health IT into HRSA programs. The OHIT office created the “HRSA Health Information Technology Community” an integrated web site developed with AHRQ. The site is a virtual meeting place for staff from the Federally 55 Federal Activities in Telemedicine, Telehealth, and Health Technology

Qualified Health Centers, health center networks, and primary care associations. The focus is to promote patient safety and quality of care. The site has an online toolkit to offer advice on budgeting for health IT, with information on funding opportunities.

Health Centers HRSA supports more than 1,500 health centers in every state and help more than 17 million individuals. In 2009, health center sites received $851 million in Recovery Act grant funds to enable 659 centers to support construction, repair, and renovations for over 1,500 health center sites. The EHR implementation initiative supports HRSA health center networks as well as existing networks along with other health information technology initiatives to implement health technologies other than EHRs.

Health Centers and Controlled Networks Grants HRSA funds HIT for Health Center Controlled Networks and Large Multi-Site Health Centers. These grants help the networks of health centers do planning activities to lead to HIT adoption. This planning can include doing HIT readiness assessments, workflow analyses, business planning, system upgrades, and developing telehealth services. The HIT Toolbox is a compilation of HIT planning, implementation, and evaluation resources to support health center grantees. The Toolbox will be expanded to include rural health, maternal and child health, HIV/AIDS, and telehealth portals.

Ryan White HIV/AIDS Program Many organizations have some type of infrastructure to collect data but gaps do exist. Funding under this program fills some of these gaps and improves existing systems. The funding through this program helps in reporting client level data, and to purchase and use electronic health information technology systems. Funds may be used for staffing, new hardware and software, or to modify systems.

Office for the Advancement of Telehealth http://www.hrsa.gov/telehealth The Office for the Advancement of Telehealth (OAT) coordinates the use of telehealth technologies across all of HRSA’s programs. OAT administers grant programs, coordinates telehealth network and resource centers, and evaluates the use of appropriate telehealth technologies. OAT provides guidance on telehealth policy through the Associate Administrator for Health IT and reports to the National Health Information Technology Coordinator, to other Federal and state agencies, and to the private sector. OAT projects involve emerging technology applications emphasizing low cost applications to improve the quality of care. It also involves the integrating information systems within and across healthcare institutions. OAT realizes that rural programs need to use integrated healthcare delivery systems or networks as a means to stabilize and integrate fragile rural health care systems. The Foundation for eHealth Initiative has established the “Connecting for Better Health Program” with funding from OAT. The Foundation program provides seed funding and support to multi-stakeholder collaboratives within communities who are using health information exchanges and other IT tools to drive improvements in health care quality, safety, and efficiency. 56 Federal Activities in Telemedicine, Telehealth, and Health Technology

Grants The Telehealth Resource Center Grant Program administered by OAT helps healthcare organizations, networks, and providers implement cost effective telehealth programs. OAT oversees the Telehealth Network Grant Program. The program demonstrates how telehealth programs and networks improve access to quality healthcare services in underserved rural and urban communities and how remote disease management and telehomecare can be effective. The grants are awarded in two ways. The Telehealth Networks (TNGP-TH) grant program supports telehealth networks in different settings such as long term care facilities, community health centers, clinics, physician offices, hospitals, schools, assisted living facilities, and homes. The funding is used to demonstrate how telehealth networks can be used to expand access, coordinate, and improve the quality of health information available to healthcare providers, patients, and their families. The other program, called Teleheomecare Networks (TNGP-THC) grants focus on telehealth networks to improve healthcare through the provision of clinical care and for remote monitoring of patients in their home using telehealth technologies.

Special Projects of National Significance Information Technology Networks of Care Initiative The SPNS Information Technology Networks of Care Initiative awards grants to organizations to help promote and evaluate existing health IT for people living with HIV/AIDS in underserved communities.

Congressionally Mandated Projects OAT administers funds for projects earmarked by Congress. The goals for these projects vary widely, but all include the use of telehealth technologies to improve access to healthcare. Emphasis is always on low cost applications to improve the quality of care and integrate the IT systems within and across healthcare institutions.

Special Projects Special Projects promote program evaluations, document the diffusion of telehealth technologies among HRSA’s grantees, provide HIT information, information for network development, data to help states, evaluates specific policy issues, and develops concepts for telehealth resource centers. HRSA has established the “Telehealth Resource Centers Cooperative Agreements Program” to help provide the Office for the Advancement of Telehealth (OAT) grantees plus others, technical assistance in establishing telehealth programs. The centers provide technical assistance and support for providers to help to form collaborations using telehealth technologies and to help rural communities. A grant was awarded to develop the Northwest Regional Telehealth Resource Center. This center helps develop new telehealth networks and applications for rural and remote areas in several western states including Alaska, Hawaii, and the Pacific Islands to provide distant clinical healthcare, education, public health, and health administration. Also, the California Telemedicine and eHealth Center Mentor Program has helped to develop telehealth programs to serve as models for telehealth. In partnership with AHRQ, HRSA has established the HIT Community for HRSA grantees to serve 57 Federal Activities in Telemedicine, Telehealth, and Health Technology

as a virtual community for health centers, networks, and State Primary Care Associations and other grantees. The portal allows team members to view important announcements and documents.

Bureau of Primary Healthcare http://bphc.hrsa.gov The Bureau of Primary Healthcare (BPHC) works to improve access to high quality comprehensive preventive and primary healthcare services to the underserved and vulnerable populations. The Office of Minority Health and Health Disparities delivers health services to special populations such as migrant and seasonal farm workers, homeless persons, women and other minorities, and special populations. BPHC established a Consolidated Health Center Program to help where economic, geographic, or cultural barriers limit access to primary healthcare for a substantial portion of the population. The program offers primary and preventive care, outreach, and dental care, and offers laboratory tests, x-rays, and pharmacy services as well as related health services. BPHC with the Health Center Information Systems workgroup provides community health centers with information on electronic medical records and disease management systems. Grants go to over 650 community-based public and private nonprofit organizations to develop and operate community health centers with funding supporting 2,500 clinics. The program delivers healthcare to more than 4,000 sites. The Bureau has a National Network for Oral Health Access to help underserved populations. The goal is to develop an oral health clinical quality infrastructure and move health IT forward to improve the quality of care.

Maternal and Child Health Bureau http://www.mchb.hrsa.gov In 2009, MCHB started working towards developing a comprehensive child health profile to establish an early pregnancy intervention program through a health information exchange. Funds will be used to build a public-private partnership between a state or RHIO, public health department, and a state Medicaid Office. The system would help to target high risk pregnant women and infants. The goal is also to implement a web-based electronic birth records system.

Divisions Division of Health Center Management The Division manages related to clinical, managerial, and financial efficiency, and helps with vulnerable populations.

Division of Clinical Quality The Division looks at the quality of clinical activities, and works on policies and programs to deliver primary healthcare including clinical information systems. Also coordinates clinical technical assistance programs for the BPHC staff. 58 Federal Activities in Telemedicine, Telehealth, and Health Technology

Division of Immigration Health Services The Division is the primary focal point within the Immigration and Naturalization Service (INS) for planning and managing policy formulation and direction and for health matters pertaining to aliens detained by the INS. Since 1985, the INS has had this interagency agreement with the Public Health Service through HRSA’s Bureau of Primary Health Care to provide healthcare personnel in medical facilities and provide other healthcare support. The program uses telemedicine and has implemented a national multi-site tele-pharmacy project in ambulatory medical clinics in selected INS detention centers. The El Paso Facility uses teleradiology to screen new arrivals for TB. Previously, it took a facility up to five days to determine if a detainee was infected with TB, but now the information is available within four hours. Detainees come from all over the world with TB, however the majority coming from Mexico and Central America.

Bioterrorism The Hospital Preparedness Program supports state efforts to provide critical emergency care in case of terrorism and other public health emergencies. HRSA is working to ensure that volunteer health professionals are able to respond in the event of a mass casualty event. The Emergency System for Advance Registration of Volunteer Healthcare Personnel is a state-based system for the pre-registration of volunteer healthcare personnel who wish to respond to an emergency or mass casualty event. HRSA provides funding to states to use for a possible mass casualty event, to expand hospital beds, develop isolation capacity, establish hospital-based pharmaceutical caches, provide trauma and burn care, and provide up-to-date communications.

Agency for Health Care Research and Quality

http://www.ahrq.gov AHRQ awards grants and contracts in telemedicine, telehealth, and informatics. The agency funds hospital-based information technology investments to enhance patient safety. This funding goes to develop technologies such as CPOE, computer monitoring for potential adverse drug events, automated medication dispensing, computerized reminder systems, handheld devices for prescription information, computerized patient records, and patient centered computerized support groups. Working with public and private partners, AHRQ uses data from hospital information technology investment demonstrations to help push proven technology through the healthcare system and to look at the impact of technology on the workforce.

Health IT http://healthit.ahrq.gov AHRQ has invested over $260 million in contracts and grants to serve primarily low income rural areas with high rates of chronic illness to over 150 communities, hospitals, providers, and healthcare systems in 48 states. AHRQ published a brief in 2009 on the grants in the health IT portfolio that implemented telehealth but the brief also showed certain trends and problems. 59 Federal Activities in Telemedicine, Telehealth, and Health Technology

The agency is implementing and evaluating innovative technologies in diverse health care settings. The goal is to:

• Provide rural hospitals and clinics with more computers and access to the internet • Develop electronic health records that are easy to use • Create better software and algorithms for provider’s palm and handheld devices • Merge clinical and public health systems to facilitate health IT • Support demonstration projects to address barriers to adoption of health IT • Study successful models that use data standards to share information • Provide no cost health IT assessment tools to providers

AHRQ provided three funding opportunities for HIT research. The funding included:

• Research demonstration projects to study how to implement health IT to improve the quality, safety, and effectiveness and efficiency of healthcare in ambulatory settings and how to support care transitions between ambulatory settings or non ambulatory settings • Exploratory development research projects to conduct pilots or feasibility studies to help implement future health IT • Small research grants in health IT to perform an economic analyses of health IT implementation and to do a secondary data analyses of health IT research

AHRQ has awarded grants to focus on sharing health information between providers, laboratories, pharmacies, and patients, and to help to ensure safer patient transitions between healthcare settings as well as reduce medication errors and unnecessary testing. The focus is to support health IT implementation in rural settings. In addition, contracts have been awarded to public-private groups to accelerate the adoption of health IT. The agency has awarded state and regional HIE projects. They include the Colorado Health Infor- mation Exchange, Delaware Health Information Network, Indiana Health Information Exchange, Rhode Island Health IT Project, Tennessee MidSouth eHealth Alliance, and the Utah Health Information Net- work.

Health Information Technology Resource Centers Health Information Technology Resource Centers provide technical assistance and consulting services to AHRQ projects involved in developing, testing, and using health IT applications, with the focus on addressing challenges to health IT implementation in rural and small community settings. The Center has access to more than 7,000 resources on key issues. In 2009, AHRQ published a solicitation for proposals to do multiple IDIQ/Task Order contracts through which individual Task Orders were awarded to support the AHRQ National Resource Centers for Health Information Technology. The ceiling amount for all contracts is up to $300 million. 60 Federal Activities in Telemedicine, Telehealth, and Health Technology

Major Health IT Initiatives • AHRQ invests in grants, contracts, and interagency agreements to establish a real-world learning lab for e-prescribing and other technologies • AHRQ wants to see health IT systems incorporated into the care of the chronically ill and is working with state health officials on electronic health records and on another project using a telehealth system to manage wound care • AHRQ has awarded $5 million for two contracts for two years to develop clinical decision support tools. The Brigham and Women’s Hospital in Boston and Yale University School of Medicine each received $2.5 million and will use the funding to incorporate clinical decision support across the health IT vendor community • AHRQ has developed an Electronic Preventive Services Selector tool for primary care clinicians to use when recommending preventive services for their patients. The tool is designed to use on a PDA or desktop computer and enables clinicians to access the latest recommendations from the Preventive Services Task Force • Funding was released through The Transforming Healthcare Quality Through Information Technology program to demonstrate the value of health IT, planning grants, and for implementing health IT within partnerships • AHRQ awarded funding to the Indian Health Service toward the development of the Indian Health Service electronic health record and to permit individual facilities flexibility in how to configure their electronic health record systems • Researchers at University of Pennsylvania Hospital received a grant from AHRQ and NIH to study disease management technologies in patients with heart failure and patients with both heart failure and diabetes. The objective is to assess the impact of health information technologies on clinical and financial outcomes for patients with heart failure • Six state and regional health IT demonstrations are now operating. The goal is to develop a health information exchange to interconnect with local health information infrastructures • AHRQ is funding a statewide regional health information exchange at the Regenstrief Institute at Indiana University. The project uses the Indianapolis Network for Patient Care to collect patient data such as lab results, clinic notes, chief complaints, diagnoses, procedures, immunizations, allergies, medications, and test results. When the system identifies cases of a reportable condition, the patient information is sent to the county and state health departments • Working with the National Governors Association to help state officials • Collaborating with CMS in evaluating demonstration projects involving health IT, helping with the DOQ-IT program, and helping with the CMS MCMP demonstration project to explore the integration of electronic health records in the ambulatory environment • Working with the HHS Office of the National Coordinator for Health IT on various state privacy laws and business practices to explore polices and state laws • Studying how health IT can treat symptomatic heart failure cases in the home and how these technologies can affect clinical and financial outcomes for rural patients • Working with the University of Tennessee to bring cutting edge cancer care to rural Tennessee 61 Federal Activities in Telemedicine, Telehealth, and Health Technology

• Funded Project Echo at the University of New Mexico along with the New Mexico Health Information Collaborative • Working with NLM to help develop standard clinical terminology for health IT applications • Measuring the penetration of health IT in smaller medical practices and studying the business case for investment in health IT • Working on the certification of health IT products so that vendors and providers will know whether the products are of high quality, and conform to standards • Looking at legal issues from privacy concerns to error reports

U.S. Health Information Knowledgebase USHIK is a health metadata registry funded and directed by AHRQ to provide and maintain a metadata registry of health information data element definitions, values, and information models to enable comparing, synchronizing, and harmonizing.

Patient Centered Medical Homes AHRQ is studying the possibly on how to develop the Patient Centered Medical Home as a model to improve primary care. The researchers will look at whether healthcare quality improves when practices are transformed into a PCMH and examine how the transformation occurred, the impact on costs of care, and how the patients rate the experience.

Ambulatory Care The agency is looking at ambulatory health centers to see how information technology can be used. The National Opinion Research Center conducting the study is using the internet and the telephone to understand the gains and challenges that healthcare organizations experience when implementing IT. AHRQ awards grants through the AHRQ Ambulatory Safety and Quality program emphasizing health IT.

Surveillance and Bioterrorism AHRQ awards research grants to study how responders can manage new tools and models in case of a bioterrorist event and other public health emergencies. The grants help prepare hospitals and health care systems for events, enhance ambulatory care, provide home and long term care, provide psychosocial care, provide technology linkages and emerging communication networks, and use novel healthcare training strategies to help community clinicians deal with emergencies. Researchers at RTI in North Carolina, along with researchers at UAB, have developed online training modules for anthrax, smallpox, botulism, tularemia, viral hemorrhagic fever, and plague. Another web-based tool at (http://www.ahrq.gov/research/epri) helps local, regional, and state planners compile customized inventories of healthcare and emergency resources. The tool enables communities to assess regional supplies of critical resources, prepare for incident response, estimate gaps, and support future resource investment decisions. AHRQ has a new computer model to help hospitals and health systems plan antibiotic dispensing and vaccination campaigns when responding to bioterrorism or to a large scale natural disease outbreak. This resource is a computerized staffing model that can be downloaded as a spreadsheet and used to 62 Federal Activities in Telemedicine, Telehealth, and Health Technology

calculate the specific needs of local healthcare systems based on the number of staff and the number of patients that need to be treated quickly. AHRQ sponsored researchers at the University of Pittsburgh are using the Real-time Outbreak and Disease Surveillance (RODS) computer system. Several studies using data from emergency department visits, such as laboratory test results and patient demographic information, showed that the RODS computer system detected acute respiratory illnesses and influenza far more quickly than the standard methods for detection. AHRQ is testing using PDA’s to transmit urgent information on biological agents to clinicians, and looking for ways for federal officials to communicate effectively with front line clinicians in emergencies. The project is evaluating the system for sending urgent “Doc Alert” messages to more than 700,000 front line clinicians, including more than 250,000 physicians. The message includes web links for clinicians to go to for additional information on diagnosing and treating the conditions caused by biological agents. AHRQ working with Children’s Hospital in Boston to develop computer systems to collect and analyze emergency department data, incorporate data into the system, provide online diagnosis and treatment, and use a decision support system designed to detect diseases early. MIT is working with AHRQ to help clinicians identify the diseases that result from bioterrorism by creating a web-based decision support tool to link patient symptoms and provide a database of potential organisms and treatment manual. AHRQ has awarded developmental grants to 36 Primary Care Practice Based Research Networks that includes primary care practices working together with academic researchers to answer community based healthcare questions and to translate these research findings into practice. The awards are developing an information technology infrastructure to better manage chronic diseases, deliver preventive services, and provide better community-based detection and response to emerging public health threats. AHRQ has a tool to help state and local officials quickly locate alternate healthcare sites if hospitals are overwhelmed by patients due to a bioterrorism attack or other public health emergency. The tool enables regional planners to locate and rank potential alternative sites such as stadiums, schools, recre- ation centers, motels, and other venues. AHRQ’s interactive web site (http://hospitalsurgemodel.ahrq.gov) has information available to help hospitals and emergency planners do a better job to identify resources to treat an influx of patients. AHRQ’s Health Emergency Assistance Line and Triage Hub (HEALTH) model was developed by researchers at Denver Health Medical Information Centers to minimize surges in patient demand on the healthcare delivery system during a bioterrorist event or other public health emergency. This helps planners determine the requirements, specifications, and resources needed for developing an emergency contact center. The agency has published a report “Training Clinicians for Public Health Events Relevant to Bioterrorism Preparedness” The report says that teleconferencing can be used to standardize bioterrorism preparedness training across geographically diverse groups. They found that satellite teleconferences may be as effective as classroom training.

Home Healthcare and Influenza AHRQ published the report “Home Health Care during an Influenza Pandemic: Issues and Resourc- es” to highlight the resources and the technology needed by home healthcare providers and community planners to prepare for such an event. 63 Federal Activities in Telemedicine, Telehealth, and Health Technology

Patient Safety In 2009, AHRQ announced that organizations in ten states are now undertaking a project to test methods to reduce Central Line Associated Blood Stream Infections in Intensive Care Units. AHRQ awarded a three year, $3 million contract to the Health Research & Educational Trust to coordinate the project and provide the tools to help reduce infections. In 2009, AHRQ awarded $618,000 via the “Accelerating Change and Transformation in Organiza- tions and Networks” initiative to study how to implement a patient safety event reporting system for consumers. Research Triangle Institute along with Baruch College and Consumers Advancing Patient Safety were selected to do the 20 month study. AHRQ is funding simulation research to study the role that simulation can play to improve the safe delivery of healthcare. AHRQ is interested in the adaptation of simulation tools in diverse healthcare settings and in evaluating the impact on patient safety. Team Strategies and Tools to Enhance Performance & Patient Safety (TeamsSTEPPS) developed by the Department of Defense Patient Safety program in collaboration with AHRQ, is an evidence-based teamwork system aimed at improving communication and other teamwork skills among healthcare professionals. TeamSTEPPS includes a comprehensive suite of ready-to-use materials and training curricula necessary to successfully integrate teamwork principles into all areas of the healthcare system. A study co-funded by AHRQ and the National Institute on Aging, found that Medicare patients treated in outpatient settings may suffer as many as 1.9 million drug related injuries a year because of medical errors or have adverse drug reactions not caused by errors. About 180,000 of these injuries are life threatening or fatal, and more than half are preventable. The researchers found that 58 % of errors were made in prescribing medications, not educating the patient adequately about the medicine, or for prescribing a medication that indicated an interaction with another drug that the patient was already taking. AHRQ has contracted with the University of Washington to develop healthcare information and communication systems policy options for state governments to increase access and effectiveness of basic health services. Software has been developed that can spot questionable overuse, under use, or misuse of procedures, and show indicators for death rates for 13 diagnoses and nine inpatient procedures at the hospital. AHRQ has a tool to help hospitals and health systems evaluate employee attitudes about patient safety in their facilities. The Hospital Survey on Patient Safety Culture released in partnership with Premier Inc., the Department of Defense, and the American Hospital Association is measuring organizational conditions that can lead to adverse events and patient harm. The survey includes a feedback report template in which hospitals enter data to produce customized feedback reports for hospital management and staff. AHRQ is involved in tracking infection data from information obtained on potential in-hospital complications and adverse events and tracks variations in healthcare-associated infections across regions using Patient Safety Indicators. Task orders have gone to mitigate HAIs at hospitals and they are using AHRQ evidence-based tools to improve infection safety. AHRQ funded an assessment program led by Indiana University to coordinate project tasks and provide technical assistance to hospitals. Through AHRQ partnership’s with states in the Healthcare Cost and Utilization project, data is reported on 90 percent of the hospital discharges in the country. In future years, as existing patient safety grants end, AHRQ wants to expand the focus on human 64 Federal Activities in Telemedicine, Telehealth, and Health Technology

factors research. The research will develop controls for technologies for easy use as in infusion pumps used to administer fluids to patients through their veins, which are often involved in patient safety adverse events. Human factor research would help researchers understand approaches for reducing inad- vertent errors in programming these pumps. Researchers are going to work with industry to improve the safety and quality of products.

Patient Safety Organization Privacy Protection Center http://www.psoppc.gov AHRQ created the PSOPPC to implement the Patient Safety and Quality Improvement Act that was passed in 2005. The Act extends legal privilege and confidentiality protections to healthcare providers who voluntarily submit patient safety information to a Patient Safety Organization. Through the use of the Common formats, patient safety information is collected and submitted to the Privacy Protec- tion Center for de-identification before it enters the Network of Patient Safety Databases.

Patient Safety Research Coordinating Center http://www.ahrq-psrcc.org The Center managed by NORC at the University of Chicago operates as a resource center to assist AHRQ in coordinating its portfolio of patient safety projects and promotes discussion and collaboration among researchers. The Center supports health IT projects funded by AHRQ, other Federal partners, and directs technical assistance and consulting services to individual projects. The Center has also launched a “Communities of Practice Initiative” so that AHRQ Patient Safety awardees can share similar research interests to stimulate discussion and to connect awardees within their communities. Some of these awardees are:

• Helping clinicians, facilities, and patients implement evidence-based patient safety practices • Developing and testing state-of-the-art clinical informatics applications • Using a set of indicators that any hospital can run against its hospital discharge data to evaluate how they are doing in terms of safety and quality • Creating a Patient Safety Improvement Corps to bring teams of state officials and private sector providers together • Working on health standards as it relates to patient safety

Another site the Patient Safety Network (PSNet) at (http://www.psnet.ahrq.gov) is a one stop portal of resources for improving patient safety and preventing medical errors. The site enables the user to develop “My PSNet” page to customize the site around their interests and needs. The site is continuously updated with information on tools and findings related to patient safety research, information on upcoming meetings, links, and an email subscription service for weekly updates. 65 Federal Activities in Telemedicine, Telehealth, and Health Technology

M &M Web Site http://www.webmm.ahrq.gov The M&M web site includes data on new cases, what went wrong, why, how the patient was harmed along with expert commentaries on how to think through such cases, identifies problem areas, and provides potential solutions. More than 10,000 healthcare professionals are registered users.

Healthcare Quality AHRQ, CMS, and OPM have launched a web site to help managers, consumer advocates, and state officials communicate on healthcare quality. The site at (http://www.TalkingQuality.gov ) provides step- by-step instructions on implementing quality measurement and reporting projects, such as a health plan report card. The Health Care Report Card Compendium (http://www.talkingquality.gov/compendium) is a searchable directory of over 200 samples of report cards produced by a variety of organizations. The Home Health Quality Initiative (HHQI) publishes home health quality measures available for home health agencies in Florida, Massachusetts, Missouri, New Mexico, Oregon, South Carolina, West Virginia, and Wisconsin. Home Health Compare information is located at (http://www.medicare.gov). The “National Healthcare Disparities Report” provides views on the quality of healthcare and differences in using the services. Future reports will help track quality through a consistent set of measures that are updated as new measures and data becomes available. The reports are available at (http://www. innovations.ahrq.gov.) Free PDA based decision supporting software called the Pneumonia Severity Index Calculator is available to help doctors see whether patients with pneumonia acquired in the community should be treated at home or in the hospital. It has been found that the software significantly reduced the costs of treating pneumonia without affecting the quality of care. The Center for Quality Improvement and Patient Safety works to improve the quality and safety of the healthcare system through research and implementation of evidence and produces annual reports on healthcare quality, disparities, and patient safety. AHRQ’s State Snapshots web tool (http://statesnapshots.ahrq.gov) helps state health leaders, researchers, consumers, and others understand the status of healthcare quality in individual states. AHRQ’s reports on “Privacy and Security Solutions for Interoperable Health Information Exchange” is available on 34 state HIE plans.

Web-Based Tools HCUPnet and MEPSnet Systems The Healthcare Cost and Utilization Project (HCUP) (http://hcupnet.ahrq.gov) is a family of healthcare databases and related software tools developed through a federal state industry partnership. The HCUP databases bring together data from state organizations, hospital associations, private data organizations, and the federal government to create a national information resource. The HCUPnet system has separate paths for lay users and researchers with more information and more details. The on-line query system gives instant access to the largest set of all payer healthcare databases publicly available. The system analyzes health statistics and information on hospital stays, includes data on hospitalizing patients, diagnostic and surgical procedures, death rates, hospital charges, costs, length of stays, and other inpatient care issues. 66 Federal Activities in Telemedicine, Telehealth, and Health Technology

The Medical Expenditures Panel Survey (MEPS) provides policymakers, healthcare administrators, businesses, and others with comprehensive information about healthcare use and costs in the U.S. MEPS includes the Household Component Survey, the Medical Provider Component survey, and the Insurance Component survey. The system generates tables and graphs on national and regulatory statistics and pinpoints trends for community hospitals in the U.S. MEPSnet is available at (http://www.meps.ahrq. gov/mepsweb). AHRQ has launched NHQRnet (http://nhqrnet.ahrq.gov) and NHDRnet (http://nhdrnet.ahrq.gov) a pair of interactive web-based tools for searching for national healthcare data.

Effective Health Care http://www.effectivehealthcare.ahrq.gov AHRQ is supporting new Comparative Effective Research Projects with funding from the stimulus package. The legislation appropriated $300 million to AHRQ to support CER and the research will focus initially on 14 priority conditions. Funding is due to begin 2010. The Effective Health Care Program publishes Comparative Effectiveness Reports developed by Evidence-based Practice Centers, develops evidence to fill knowledge gaps about treatment effectiveness, and works to communicate complex scientific findings to a variety of audiences. This information helps clinicians and patients determine which drugs and other medical treatments work best for certain health conditions. The program has a network of centers called DEcIDE to support work in 13 centers to perform research on clinical effectiveness. The Centers collectively provide access to medical data for over 50 million patients, including Medicare’s 42 million beneficiaries. Studies on outcomes, comparative clinical effectiveness, safety, and appropriate services are available. Initial research has focused on the outcomes of prescription drug use and other interventions for which randomized controlled trials would not be feasible or timely. AHRQ has developed a handbook to serve as a guide to developing registries. The handbook is a database of confidential patient information to use to understand and compare the outcomes and safety of healthcare. The idea is to use registries to develop better strategies to evaluate new treatments especially treatments that affect very small segments of the population that have been exposed to specific diseases. AHRQ works with a stakeholder group to provide advice for the program, identify critical research gaps, look at implementation issues, identify useful projects, and provide guidance on quality improvement. AHRQ with additional funding from RWJF prepared a 1,400 page handbook for nurses on patient safety and quality. The handbook is titled “Patient Safety and Quality: An Evidence-Based Handbook for Nurses.” Guides have been published to help clinicians, and patients make treatment choices for rheumatoid arthritis, high blood pressure, and Type 2 diabetes. In addition, new Spanish language versions are available for some of the consumer publications.

National Quality Measures Clearinghouse http://www.qualitymeasures.ahrq.gov AHRQ’s National Quality Measures Clearinghouse is a public repository for evidence-based quality measures and measure sets. The Clearinghouse contains an AMA/Physician Consortium and HealthPart- 67 Federal Activities in Telemedicine, Telehealth, and Health Technology

ners measures along with summaries. An inventory of quality measures to use for reporting, payment, or quality improvement is available. The measures can be sorted by agency or operating division.

National Guideline Clearinghouse http://www.guideline.gov The Clearinghouse is similar to NQMC, but is guideline focused and contains Evidence-based Practice Center reports and annotated bibliographies.

Rural Health Care http://www.ahrq.gov/research/ruralix.htm AHRQ addresses healthcare needs and health policy issues of rural Americans. The agency examines managed care, rural health networks, integrated delivery systems, disparities in health services access and use, and how to care for vulnerable populations in rural areas. AHRQ also supports research on the applications of healthcare IT for children in rural and urban areas. Researchers are studying telemedicine in rural pediatric practices, how to increase the efficiency of routine pediatric care in urban and suburban areas, and exploring whether telemedicine could replace a large proportion of emergency department and office visits. Specifically AHRQ funding is working on a patient safety reporting system. Researchers are examining incidents and trends in several rural settings in order to understand the cause of errors in primary care practices. AHRQ is looking at the relationship between working conditions of healthcare providers and the quality of care provided in rural hospitals.

Health Literacy Research The goal is to develop better methods to help healthcare providers communicate scientifically- based health information to the public. Research funding is evaluating information technologies so that consumers can seek, access, and interpret relevant health information effectively. New pilot tools and technologies are needed to identify health literacy barriers to distinguish among persons with low literacy skills, and those individuals that have learning or communication disorders. Researchers are identifying the mix and skills that are required to be functionally health literate and exploring the variation and magnitude of group characteristics. Technologies are needed that relate to data reduction, data mining, knowledge extraction, and how to improve existing databases.

National Guideline Clearinghouse http://www.guideline.gov A full text retrieval system developed by AHRQ in conjunction with NLM, provides users with electronic access to guidelines. AHRQ in collaboration with the American Association of Health Plans and the American Medical Association developed a comprehensive internet-based source for clinical practice guidelines called the National Guideline Clearinghouse (NGC). The Clearinghouse provides current guidance on treatments for specific medical conditions, and provides physicians, nurses, and other healthcare providers with a comprehensive resource on evidence-based clinical practice guidelines. The layout of the site and the standardized abstracts and tables allow users to quickly compare similar guidelines by different organizations with new guidelines added weekly. 68 Federal Activities in Telemedicine, Telehealth, and Health Technology

Other Research Projects AHRQ has funded a new coordinating center and 10 research centers as part of the Centers for Education and Research on Therapeutics program to increase the awareness of the benefits and risks of therapeutic products, including prescription medicine, biological products, and medical devices. Each center works with AHRQ and FDA on advancing the optimal use of medications, medical devices, and biologic products. AHRQ has initiated Accelerating Change and Transformation in Organizations and Networks (ACTION) awards to provide for partnerships for applied research. The idea is to promote innovation in healthcare delivery by accelerating the diffusion of research into practice. The ACTION program includes 15 large partnerships and collaborating organizations.

Healthcare Innovations Exchange http://www.innovations.ahrq.gov The Exchange looks for organizations to submit information on a broad range of novel healthcare strategies, activities, and tools from pioneering programs. The strategies can be used to improve the management for specific chronic conditions and ways to increase access to care for people with disabilities and underserved populations. The Exchange acts as a repository for successful healthcare innovations and makes the information available to the public. The Exchange includes descriptions for innovations that failed to encourage information sharing and reduce duplication.

SBIR Program http://grants.nih.gov/grants/funding/sbir.htm AHRQ awarded SBIR contracts to develop tools for patients to monitor their health, methods for electronic sharing of patient medical records, to provide for internal-based communications between patients and providers, handheld devices for patients and providers, decision support applications for patient self-care, patient safety, and chronic disease management. Several of these programs have developed prototypes of devices that have the potential to improve patient self-care and self-monitoring.

Center for Medicare and Medicaid Services http://www.cms.hhs.gov

2009 Stimulus Funding for Medicare The health IT provisions for Medicare the stimulus package provides monetary incentives to adopt EHRs. Incentives will help physicians practicing in fee-for-services, hospitals and sometimes in Medi- care advantage organizations. In order to receive the incentive payments, adopters have to demonstrate their meaningful use of EHRs. Incentive payments will be put in place over a six year period, however, if health IT is not adopted, than penalties will be put into place. Hospitals will also receive incentive payments for the first five years to make use of EHR technology. If an eligible hospital does not make meaningful use of the EHR technology by 2015, their reimbursement payments will be reduced. 69 Federal Activities in Telemedicine, Telehealth, and Health Technology

Stimulus funding is making possible a nationwide effort to reduce healthcare associated infections in stand alone or same day surgical centers to be administrated by CMS. In 2009, 125 ambulatory surgical centers were surveyed at an estimated cost of $1 million.

Advisory Committee The CMS Medicare Evidence Development and Coverage Advisory Committee (MedCAC) makes recommendations on specific issues pertaining to Medicare, reviews and evaluates medical literature, and looks at technology assessments. The committee members are selected for their expertise in clinical and administrative medicine, biologic and physical sciences, public health administration, patient advocacy, healthcare data, information management and analysis, healthcare economics, medical ethics, and other related disciplines.

Funds for Alternatives to Institutional Care States have received grants to use to increase the awareness of home and community-based long term care options for people leaving hospitals who otherwise might enter a traditional nursing home. The grants are part of the Real Choice Systems Change program which helps states rebalance their long-term support programs to help people with chronic diseases.

Telemedicine/Telehealth CMS is organized into three centers to support cooperative agreements to demonstrate and evaluate the effectiveness of rural telemedicine systems, projects to develop pilot tests, and projects to evaluate payment methodologies for telemedicine consultations. The Medicare legislation put in place in July 2008, allows telemedicine/telehealth to be used in originating site in skilled nursing facilities, hospital-based dialysis centers, and community mental health centers. Reimbursement is provided for:

• Teleradiology provides the largest number of remote medical services delivered and is fully integrated into the Medicare reimbursement system as teleradiology requires no special codes or identifiers • Remote cardiac monitoring and pacemaker monitoring are covered by special CPT codes • The rural program provides only designated medical services at designated sites, and reim- burses for live video telemedical services to non-metro areas • The use of a telecommunications system may substitute for a face-to-face hands on encounter for individual psychotherapy, pharmacologic management, psychiatric diagnostic interview examination, end stage renal disease related services, and individual medical nutrition therapy

Every year, CMS publishes information on telehealth services that Medicare will cover. Each year, CMS accepts requests to add telemedicine or telehealth services that must be submitted by December 31st of each year. CMS has clarified the interpretative guidelines concerning hospitals or Critical Access Hospitals 70 Federal Activities in Telemedicine, Telehealth, and Health Technology

(CAH) and on-call physician requirements under the Emergency Medical Treatment and Labor Act. Now on-call physicians can use telehealth technology to aid in consultations with specialists who are not present in the hospital or in Critical Access Hospitals.

e-Prescribing Medicare is working towards speeding the adoption of e-prescribing by offering incentive payments to physicians for e-prescribing. As of 2009 and for the next four years, Medicare will provide incentive payment to eligible professionals to become electronic prescribers. Eligible professionals will receive 2 percent incentive payments in 2009 and 2010, and a one percent incentive payment in 2011 and 2012, and a one half percent payment in 2013. CMS also issued a final rule to establish Part D e-Prescribing standards for four types of information. They are formulary and benefits, medication history, fill statues notification, and identification of individual healthcare providers.

Personal Health Records CMS encourages Medicare beneficiaries to use Personal Health Records. CMS developed a pilot program so that beneficiaries would be able to maintain their health records electronically. The states of Arizona and Utah are participating in the pilot and beneficiaries can choose one of the selected commercial PHR tools and then CMS will transfer up to two years of the individual’s claims data into the individual’s PHR.

CTI The Council on Technology and Innovation (CTI) provides CMS with improved methods to develop information about the clinical benefits of new medical technologies. The Council addresses the process for Medicare coverage, coding, payment for new technologies, and the exchange of information on new technologies between CMS and other entities. The Council has two working groups. The Effective Innovation Working Group explores ways that CMS can better anticipate and accommodate new technologies, and the other group, the Better Evidence Working Group identifies and develops study methods for gathering evidence about the risks and benefits of new and existing medical technologies.

Pay-for-Performance and Other Demonstration Programs http://www.cms.hhs.gov/DemoProjectsEvalRpts In 2009, the Secretary announced the establishment of the Medicare-Medicaid Advanced Primary Care Demonstration to enable Medicare-Medicaid innovative state-based advanced primary care initiatives. The demo will establish effective Advance Primary Care models in all parts of their states and include Medicare and Medicaid in their programs. Several new demonstration programs were started in 2009. The Nursing Home Value-Based Purchasing Demonstration is rewarding facilities that can improve or deliver high quality care in four specific areas such as staffing, resident outcomes, avoidable hospitalizations, and reductions in deficiency citations. 71 Federal Activities in Telemedicine, Telehealth, and Health Technology

Nearly 200 nursing homes in three states (New York, Wisconsin, Arizona) will participate in the demonstration and will reward those facilities that improve or deliver quality care in four areas to include nurse staffing, resident outcomes, avoidable hospitalizations. Points will be awarded to those homes with the highest scores or greatest improvement. Savings that result from improved quality and efficiency will be used to fund incentive pools in each state. The demonstration will run until June 2012. The Physician Hospital Collaboration Demonstration began July 2009 and has twelve hospitals participating and is administered by the New Jersey Hospital Association. The demonstration will operate with physician groups and 72 hospitals in a limited number of geographic areas across the country. The project will track patients beyond a hospital episode to determine the impact of hospital physician collaborations on preventing short and longer term complications and duplication services. The Medicare Medical Home Demonstration will enable up to eight states to provide targeted, accessible, continuous and coordinated family centered care to Medicare beneficiaries with high needs. The sample size will include 400 practices, 2,000 physicians, and 400,000 Medicare beneficiaries. The demonstration is expected to begin January 2010. The Medicare Hospital Gainsharing Demonstration program will test and evaluate methodologies between hospitals and physicians, how to govern inpatient hospital resources and physician work, and how to improve operational and financial hospital performance. CMS has a demonstration project to advance the use EHRs that includes 12 communities to improve the quality of health care. CMS will financially reward the delivery of high quality care if that care is supported by the use of electronic health records in physician practices. The program will accept 1,200 physicians and run for five years. In addition to the bonus payments, payments may also be awarded based on a standardized survey measuring the number of EHRs that physician groups have incorporated into their practices. The Medicare Acute Care Episode Demonstration provides global payments for acute care episodes within Medicare fee-for-service. The focus is on select orthopedic and cardiovascular inpatient procedures. Sites have been selected for the demonstration and include the Baptist Health System in San Antonio, Oklahoma Heart Hospital in Oklahoma City, Exempla Saint Joseph Hospital in Denver, Hill- crest Medical Center in Tulsa, and Lovelace Health System in Albuquerque CMS with Abt Associates has a Home Health Pay-for-Performance Demonstration to determine if incentive payments to home health agencies will improve the quality of care for Medicare beneficiaries. The project began in 2008 and will operate for 2 years in Connecticut, Massachusetts, Alabama, Georgia, Tennessee, Illinois, and California. The “Performance-Based Payments for Physicians Demonstration” a three year program is studying how to pay physicians for the quality of care that they provide to seniors and disabled beneficiaries with chronic conditions in solo or small to medium size group practices. These physicians in these practices must be providing primary care to at least 50 fee-for-services Medicare beneficiaries. In the first year of the demonstration, almost all of the 610 participating small and solo physician practices were rewarded for performance on 26 quality measures. The Physician Group Practice Demonstration is the first pay-for-performance initiative for physicians under Medicare. Incentives are available for physician groups to coordinate the overall care delivered to Medicare patients. In 2008, it was announced that ten physician groups earned $16.7 million in incentive payments. All ten of the physician groups participating in the demonstration achieved benchmark performance on at least 28 of the 32 measures as reported in year three of the demonstration. Two 72 Federal Activities in Telemedicine, Telehealth, and Health Technology groups Geisinger Clinic in Danville PA and Park Nicollet Health Services in St. Louis Park, MN achieved benchmark performance on all 32 performance measures. The Premier Hospital Quality Incentive Demonstration provides financial rewards to hospitals to demonstrate high quality performance in acute care areas. CMS partnered with Premier Inc., a nationwide organization of not-for-profit hospitals to reward top performing hospitals. First year results show that the quality of care was significantly improved with the focus on congestive heart failure, coronary artery disease, diabetes mellitus, hypertension, as well as preventive services. Ten large physician groups and 250 hospitals participated across the U.S. Outcomes measures reported on the progress of acute myocardial infarction, heart failure, and coronary artery bypass graft. Participating hospitals in the demonstration raised overall quality by 11.8% in two years in five clinical areas and provided better care for more than 800,000 patients. In year two, CMS awarded payments of $8.7 million to 115 top performing hospitals representing the top 20% of hospitals in each of the project’s five clinical areas. CMS has approved a three year extension involving more than 250 hospitals. CMS is starting to develop a Physician VBP Plan to move from the PQRI pay-for-reporting approach to a performance-based approach A demonstration under a cooperative agreement with Columbia University focused on monitoring and caring for Medicare diabetic patients residing in medically underserved inner city and rural areas. The demonstration involves remote patient monitoring and interventional informatics, developing automated clinical guidelines and standards, and developing specialized curricula for healthcare professionals. Rural area demonstration projects are collecting information to lead to a payment policy to increase capabilities of telemedicine into the Medicare program. There are several telemedicine centers taking part in Medicare demonstration projects, such as East Carolina University, Mercy Foundation and their rural telemedicine project, Iowa’s Health System Project, along with West Virginia University, the University of Michigan, and the Medical College of Georgia The Medicare Care Management Performance Demonstration is a pay-for-performance three year pilot with physicians to promote the adoption and use of health information technology to improve quality and reduce hospitalizations for chronically ill patients. Doctors who meet or exceed performance standards set by CMS receive a bonus payment for managing the care of eligible Medicare beneficiaries. The pilot shows that it does not cost Medicare more than the program would have spent on the beneficiary otherwise. A three year demonstration project called the Care Management for High Cost Beneficiaries Dem- onstration helps providers coordinate and provide better care to Medicare beneficiaries at lower costs. A number of organizations are participating in the program. One project called “Advancing Chronic Care through E* Health Networks and Technologies (ACCENT)” is testing how physicians and hospitals can best provide care for Medicare patients with chronic diseases. The program is implementing a physician led technology supported care management program for up to 2,000 Medicare beneficiaries with congestive heart failure, chronic obstructive pulmonary disease, and diabetes The Medicare Health Care Quality Demonstration is studying how incentives can improve healthcare safety, quality, and efficiency, and use best practice guidelines to identify, develop, test, and disseminate major multi-faceted improvements. Eligible organizations include physician groups, along with integrated delivery systems and regional coalitions of physician groups including other payers Hospital Quality Incentive Demonstration shows continued quality improvement among participating hospitals. The HQID is sponsored by Medicare in partnership with Premier, Inc. The demonstration 73 Federal Activities in Telemedicine, Telehealth, and Health Technology

taking place in 38 states was designed to test payment incentives to see if they would improve the safety, quality, and efficiency of inpatient service by linking incentives to improved quality.

Quality Improvement Organizations Medicare has launched a billion dollar program to provide consumers with better information on the quality of care they receive and reward providers for the quality of care that they deliver. The Quality Improvement Organizations (QIO) help providers measure clinical quality and performance and if needed, change how patient care is delivered with the focus on nursing homes, home health agencies, hospitals, and physician offices. The QIOs are assisting small and medium size physician practices interested in adopting and using electronic health records. As part of a contract with CMS, the free assistance helps doctors assess and redesign their office workflow and care processes. Help is provided on using health information technology. CMS has awarded contracts for the 9th Statement of Work for the 53 contractors participating in the QIO. The 9th SOW will initiate working on projects that span the entire spectrum, focus on quality improvement resources where they are needed the most, develop a more robust monitoring framework, and address disparities issues across the continuum of care.

Care Transitions Project In 2009, 14 communities were chosen for a pilot program to improve quality as patients move across care settings to reduce the rates for hospital re-admissions. The program will look at all aspects of how patients can transition between healthcare settings and then design customized solutions to address the underlying local drivers of re-admissions.

Chronic Care Improvement Programs CMS awarded ten Medicare chronic care pilot programs to last three years that involves 150,000 to 300,000 Medicare recipients. This program provides information on starting and maintaining a national chronic care management program in the U.S. The program monitors people electronically with diabetes, asthma, congestive heart failure, and other chronic diseases in their home. A low cost prescription plan provides savings each month. The Medicare Health Support Program is designed to help beneficiaries with diabetes and congestive heart failure reduce health risks and protect the quality of life. Eight Medicare Health Support pilot programs were offered in different areas of the country. The regions represent a mix of rural and urban areas and include ethnically and culturally diverse populations. The program provides nurse coaches, reminders, health IT, home monitoring equipment, prescription drug counseling, and provides home visits and intensive case management when needed. Phase I will run for three years and will be evaluated through comparison of outcomes for the beneficiaries who were invited to participate and those beneficiaries chosen at random. Phase II is the expansion phase. The program is operating in Oklahoma, Washington D.C., Maryland, Western Pennsylvania, Mississippi, Northwest Georgia, Illinois, Central Florida, and Tennessee. 74 Federal Activities in Telemedicine, Telehealth, and Health Technology

Reporting Infection Data CMS is using several systems to report infection data. The Medicare Patient Safety Monitoring System identifies the rates of specific adverse events within the Medicare population using inpatient medical records and administrative. The CMS Reporting Hospital Quality Data for Annual Payment Update System enables hospitals to report on infection related measures with the data y reported and available on the CMS Hospital Compare website. CMS plans to use the updated ICD-10 system to improve the collection of healthcare-associated infections data, and ICD-10 should be ready by 2011.

National Transplantation Sentinel Network CMS is looking to establish the Transplantation Sentinel Network to improve allograft quality by reducing disease transmission, including infection and malignancy from donors to recipients. In Septem- ber 2009, CMS released a Request for Information to obtain information on how to develop, operate, and manage the Network.

2009 Stimulus Funds for Medicaid The health IT incentives for Medicaid provide funding for EHR adoption that includes providers that take care of a high volume of Medicaid patients with more payments going to states with high unem- ployment

Medicaid Information Technology Architecture The Medicaid Information Technology Architecture (MITA) is transforming business and information technology across Medicaid to improve the administration of the program. The program envisions adopting standards to provide interoperability between state organizations and clients, web-based access and integration, software reusability, use of COTS software, the integration of public health and clinical data, and to provide for secure data exchange.

State Medicaid Programs http://www.cms.hhs.gov/states CMS funded grants in programs in 20 states to help improve access to primary medical care so that Medicaid beneficiaries could avoid improper use of costly hospital emergency rooms. The funds provide for new community health centers, extend the hours of operation at existing clinics, provide for education for beneficiaries, and provide for electronic health information exchange between the facilities. States are to use Medicaid “Transformation Grants” to fund research and design ways to transform the Medicaid system so that the quality and efficiency of care improves. The states need to look at reducing patient error rates, waste and fraud, expenditures for covered outpatient drugs, improving the coordination of care through care management programs, implementing P4P programs, emphasizing prevention steps, improving access to care for the uninsured, and implementing a medication risk management program as part of a drug use review program. A number of state legislatures have proposed new legislation to enable Medicaid to use health IT. 75 Federal Activities in Telemedicine, Telehealth, and Health Technology

Even though Federal Medicaid law does not recognize telemedicine as a distinct service, reimbursement may be a state option when telemedicine is used as a cost-effective alternative to the more traditional ways of providing medical care. Most states providing payment for services using telemedicine technology do so in the form of a physician consultation. Non physician practitioners may also be covered depending on their scope of practice under state law. Teleradiology is covered by all 50 states because of its prevalent use in many radiology practices. Some states have enacted legislation to require providers using telemedicine technology across state lines to have a valid state license in the state where the patient is located. So far, the states with Medicaid reimbursement for various forms of telemedicine and telehealth, include Arkansas, California, Georgia, Illinois, Indiana, Iowa, Kansas, Louisiana, Minnesota, Montana, Nebraska, North Carolina, Oklahoma, North Dakota, South Dakota, Texas, Utah, Virginia, West Virginia, Kentucky, and Maine. Twenty seven state Medicaid programs will reimburse some for telehealth services especially for behavioral health issues. Most states recognize physician consultations when using interactive video teleconferencing. For example, in Minnesota, the Medicaid agency recognizes physician consultations using interactive video or store-and-forward technology, and interactive video consultations when there is no physician present in the emergency room, if the nursing staff requests a consultation from a physician in a hub site. However, Kansas recognizes home healthcare and mental health services already covered by the state plan when using video equipment. Some states have passed legislation on private payer reimbursement for telemedicine services. California has passed legislation that prohibits health insurers from requiring face-to-face contact between a healthcare provider and patients for services provided through telemedicine. Kentucky prohibits Medicaid and private insurers from excluding services simply because telehealth services were provided. In Oklahoma, healthcare plans cannot deny coverage for healthcare if the services were provided through audio, video, or data communications. Texas prohibits some health benefit plans from excluding medical care if provided through telemedicine.

Working with IT Vendors The CMS DOQ-IT program makes high quality affordable systems more available by working with EHR vendors to overcome obstacles and provide assistance to physician’s offices. This includes helping physician offices make IT adoption decisions, implementing and making workflow more efficient in offices, and improving office efficiency using IT. CMS has released an evaluation version of VistA-Office Electronic Health Record (VistA-Office) which is an adaptation of the VHA electronic health record technology. The evaluation version is distributed by qualified vendors and evaluated for usability, effectiveness, implementation, and potential for interoperability.

Office of Equality and Civil Rights http://www.hhs.gov/ocr The Office of Equal and Civil Rights (OCR) develops policy guidance, public education, and technical assistance materials for health providers, health plans, and clearinghouses to maintain individual medical information. OCR supports the expenses associated with implementing compliance and enforce- 76 Federal Activities in Telemedicine, Telehealth, and Health Technology

ment of the HIPAA privacy rule. Due to passage of the Recovery Act, the Office will have the authority to administer and enforce HIPAA and will develop the regulations and guidance required under the HITECH to strengthen the privacy protections of HIPAA.

OCR activities include:

• Participation in the AHIC workgroups • Staff participation on NCVHS • Collaboration with ONC to develop a confidentiality, privacy, and security framework for electronic exchange of health information • Collaboration with CMS on e-prescribing and other CMS health IT programs • Led a national teleconference explain how the HIPAA Privacy Rule applies to PHRs

Collaborative Efforts CMS expanded the South Carolina Personnel Health Record pilot to include TRICARE data. An interagency agreement between CMS and DOD enables beneficiaries who have Medicare and also receive TRICARE benefits to be able to add TRICARE health data to their personal health records. Through public-private partnerships, CMS, and public health partners at the state and local levels (such as ASTHO, NACCHO, CSTE, APHL, etc.) are working on collaborative efforts. These collaborations address public health needs by leveraging current healthcare information systems and other existing electronic healthcare data sources to improve public health surveillance. CMS in collaboration with CDC, AHRQ, plus other private sector partners has launched a patient safety initiative called the “Surgical Care Improvement Project” to eliminate surgical complications. CMS has launched a state-of-the-art satellite network to provide Medicare and Medicaid information to 57 Indian Health Service and tribal health facilities in 24 states including Alaska. The network uses direct TV dishes in homes, with the dish receiving one channel called the CMS Medicare Learning Network. The 57 Indian Health Service and tribal sites complement the 83 dishes already in operation. The service is also available to more than 40 private sector sites that volunteer to show Medicare Learn- ing Network broadcasts. Two healthcare quality alliances, the Ambulatory Care Quality Alliance and the Hospital Quality Alliance have formed a new national Quality Alliance Steering Committee to work closely with CMS and AHRQ. This committee is coordinating and expanding several ongoing pilot projects designed to combine public and private information to report on performance.

Question and Issues Database http://www.cms.hhs.gov CMS has launched an online question and issue database to assist in identifying, prioritizing, and resolving important policy, operational, technical, and other questions related to MMA. Users can enter questions with information going to CMS offices for review and analysis. CMS provides answers or clarifications with telephone calls and written communications. 77 Federal Activities in Telemedicine, Telehealth, and Health Technology

Hospital Compare Web Site http://www.hospitalcompare.hhs.gov The site is a quality tool that has information on hospitals in specific areas and compares the quality of care that hospitals provide to adult patients with certain medical conditions. The site compares 17 measures in hospitals starting with eight measures related to heart attack care, four measures to heart failure care, and five measures to pneumonia care.

Research CMS funds research to modernize health IT systems to increase quality and efficiency. CMS is encouraging states to look at electronic health records, clinical decision support tools, e-prescribing, electronic tools to improve the coordination of care, and ways to implement P4P programs.

Research Reports The CMS Active Projects Report is an annual publication listing CMS research projects, and describes the agency’s research priorities research activities listed by topic. The reports are organized by themes and present a brief description of each project. The report is available at (http://cms.hhs.gov/ ActiveProjectReports). The Office of Research, Development, and Information has gathered research reports from major investment firms, summarized their analyses, and condensed the information into reports for CMS, Congress and their staffs. The reports include several major points as:

• Home Health Agency (HHA) industry growth is curtailed by the BBA and the interim payment system. The number of Medicare home health agencies have stabilized under the new prospective payment system, which appears to have encouraged providers to streamline operations and efficiently deliver services • HHA Companies continue to have difficulty raising capital primarily due to their small size. Wall Street analysts suggest that investors will provide capital once government payment policy provides more stability and predictability • Large respiratory and infusion therapy services companies demonstrate strong operational and financial performance and are able to attract investor’s capital. Where strategic and attractively priced targets are available, these companies are actively consolidating the industry and are likely to continue acquiring smaller providers. • Large home health providers benefit from the efficiencies achieved from their economies of scale and information technology improvements.

Centers for Disease Control and Prevention

http://www.cdc.gov CDC health protection goals include preparedness, health promotion, and prevention of disease, injury, and disability. To reach these goals, CDC is focusing on six strategic directions. They are health 78 Federal Activities in Telemedicine, Telehealth, and Health Technology

impact, public health research, and leadership for the nation’s health system, global health, effectiveness, and accountability. The Office of the Chief Science Officer, Office of Public Health Practice is within the Office of the Director. The Office has several divisions including the Division of Professional Development and Evalu- ation, Division of Laboratory Systems, and the Division of Public Health Systems Development and Research. The Management Information Systems Office is developing and supporting enterprise business systems such as finance, human resources, and grants. The Office reports to the CIO and is responsible for security, new technology integration, and data management.

Cardiovascular Disease CDC published the “Atlas of Stroke Hospitalizations among Medicare Beneficiaries”. This Atlas is the fifth in a series of CDC atlases related to cardiovascular disease. It was developed in collaboration with CMS and includes county-level maps of stroke hospitalizations by stroke-subtype, race/ethnicity, discharge status, and co-morbidity. Maps of hospital facilities and stroke specialists are also included.

Environmental Public Health Tracking Network http://ephtracking.nh.gov The EPHT Network was established to reduce the burden of many chronic diseases and bring together data concerning some health and environmental problems. The goal is to provide information to help improve living and reducing diseases. The Environmental Tracking Program and produces health effect data about health conditions and diseases especially chronic diseases. Information is included on environmental hazards, and exposure data.

Centers and Programs for Surveillance The CDC Infection Tracking System is available to all U.S. hospitals and is built upon CDC’s National Nosocomial Infection Surveillance System (NNISS). The new National Healthcare Safety Network (NHSN) built upon the NNISS is providing multiple options for data analysis and more flexibility for sharing information both within and outside a facility. CDC anticipates releasing more options for the system to help the states participating in NHSN measure MRSA among both in patients and outpatients. CDC currently supports more than 1300 hospitals in 16 states using NHSN to fulfill state reporting requirements. CDC funded a bioterrorism syndromic surveillance demonstration program to obtain 20 million ambulatory care patient records in real-time in all 50 states for clusters of symptoms associated with bioterrorism agents. The consortium collaborates with CDC, state, and local health departments, DOD, and other organizations. The consortium includes Massachusetts based Harvard Pilgrim, a managed healthcare organization, Harvard Vanguard Medical Associates, Harvard Medical School, and Brigham and Women’s Hospital. Also included are Minnesota based Health Partners Research Foundation, Optum, Kaiser Permanente of Colorado, the American Association of Health Plans. CDC is establishing a Bio-Intelligence Center to analyze and interpret data information and to provide appropriate communication channels to send the information and analysis back to state and local health officials. 79 Federal Activities in Telemedicine, Telehealth, and Health Technology

CDC is developing a Rapid Response and Advanced Technology Laboratory at the National Cen- ter for Infectious Diseases. This laboratory specializes in the triage and analysis of biological specimens suspected as potential agents of terrorism. The system has been expanded to member labs in all 50 states, plus five labs in Australia and two in Canada.

Public Health Emergency Preparedness Programs CDC has launched their web-based environmental Public Health Tracking Network. That will help track environmental exposures and chronic health conditions. This tool unites vital environmental information with information on some chronic conditions such as asthma, cancer, childhood lead poisoning, and heart disease into one resource. CDC is working with foreign governments through their Ministries of Health or other responsible Ministries for human health on public health emergency preparedness. CDC provides the technical assistance or techniques for identifying viruses and provides technical consultations to help the countries develop surveillance systems. CDC is awarding grants to detect and respond to emerging public health threats. The grants fund studies at Centers of Excellence such as Public Health Informatics located at the New York Department of Health and Hygiene, the University of Utah, and a Johns Hopkins University. Studies involve public and private sector partners including universities, health departments, and research organizations. Grants for $4.37 million were awarded in September 2009, to fund new Centers of Excellence in Public Health Informatics, at Harvard Pilgrim Health Care, Indiana University, and the University of Pittsburgh. CDC and CMS are collaboratively working on a common set of data requirements for monitoring infections and adhering to prevention guidelines. CDC and CMS are working on data requirements to measure MRSA as part of CMS’s Ninth SOW for the QIO program. The CDC is looking into the planning and developing of regional surveillance collaborative to identify and track diseases. Technology is needed to follow up on aberrations in patterns of health detected problems and using syndromic surveillance is simply too large to centralize in one agency.

Centers and Programs to Improve Emergency Preparedness and Response • National Center for Health Marketing—Strengthens health communication networks across federal, state, and local levels with program such as Epi-X, and the Emergency Communication system that manages the CDC Emergency Preparedness and Response web site • National Center for Immunization and Respiratory Diseases—Conducts vaccine research to protect against anthrax and other diseases • National Center for Public Health Informatics—Identifies public health informatics solutions for outbreak investigation, event detection, and monitoring. Supports the BioSense system with 800 registered users connecting with more than 600 hospitals • National Center for the Preparedness, Detection, and Control of Infectious Diseases— manages the Laboratory Response Network. The LRN maintains an integrated network of state and local public health, federal, military, and international laboratories • National Electronic Disease Surveillance System—designed to detect outbreaks rapidly and electronically and then transfer the information from clinical information systems to public health departments 80 Federal Activities in Telemedicine, Telehealth, and Health Technology

• Early Aberration Reporting System—city, county, and state public health officials in the U.S. use the system to obtain syndromic data from emergency departments, 911 calls, physician offices, schools, businesses, and from pharmacies • Early Warning Infectious Disease Surveillance Program—is a collaboration of state, federal, and international partners to provide rapid and effective laboratory confirmation for urgent infectious disease case reports in the border regions of the U.S., Canada, and Mexico • Enhanced Surveillance Project—works with state and local health departments and information system contractors to develop real-time special event syndromic surveillance and analytical methods. During events, ESP monitors sentinel hospital emergency department visits data and reports the information to state and local health departments for confirmation and follow-up • National Notifiable Disease Surveillance System—is a state-based public health surveillance system for conditions designated by the Council of State and Territorial Epidemiolo- gists as nationally notifiable • Emerging Infections Program--operates through state and local health departments to fund population-based surveillance and develop next generation surveillance science with public health agencies and academic medical centers

System Research The Prevention Epicenter Grant Program tests how electronic health information can be used to reduce infections. The funding focuses on identifying and preventing infections including antimicrobial resistant, surgical site, drug-resistant staph, and catheter-associated bloodstream infections. Software has been created to enable physicians to search electronic medical records for signs of emerging diseases with public health consequences, and then be able to report this information to public health officials. A project is establishing three-way communications among physicians, public health officials, and owners of personal health records. The project focuses on influenza immunizations for high risk populations and the data is linked to a Massachusetts site.

State and Local Readiness CDC works to develop state and local public health readiness, specifically to enhance capacities to detect, respond, contain and recover from biological, chemical and radiological acts of terrorism. Funding is available to upgrade state and local capacity, provide better electronic communications, and provide distance learning and cooperative training at public health agencies and local hospitals. HHS has awarded funds for pandemic influenza preparedness, support for the Cities Readiness Initiative, funding to improve early detection and surveillance for chemicals, and to help the states bordering Canada and Mexico including the Great Lakes States have capabilities to detect, investigate, and report urgent infectious disease cases. PulseNet a network of state public health laboratories is providing DNA fingerprinting for Salmonella and other bacteria. PulseNet Europe, PulseNet Asia Pacific Rim, and PulseNet Latin America are also operating. Fifty states have bioterrorism response plans in place with established systems to rapidly detect a 81 Federal Activities in Telemedicine, Telehealth, and Health Technology

terrorist event through mandatory reportable disease detection systems, and the states are updating their laws for dealing with public health emergencies. The states are supporting public health functions. For example:

• Michigan has implemented a secure web-based disease surveillance system to improve the timeliness and accuracy of disease reporting • Missouri has implemented a new hospital tracking system to detect possible outbreaks by monitoring the number of patient admissions and ambulance diversions at hospitals. • Virginia, Maryland, Washington D.C., and Pennsylvania are all developing early warning systems based on symptom data from emergency departments to detect unusual patterns of illness and then alert hospitals and public health agencies

The Health Alert Network (HAN) (http://w2a.cdc.gov/han/Index.asp) is being developed with the National Association of Counties and City Health Officials, the Association of State and Territorial Health Officials, and other health organizations to help upgrade the capacity of state and local health agencies to communicate different health threats such as emerging infectious and chronic diseases, and bioterrorism. HAN provides high-speed internet connectivity to support rapid information access, supports broadcast capacity to support emergency communications, and provides distance learning infrastructure for training. Funding and technical assistance is provided to all states, large cities and territories. Since 9/11, CDC has issued over 150 health alerts.

National Center for Chronic Disease Prevention and Health Promotion http://www.cdc.gov/nccdphp The Center has funds to help national organizations to establish national programs to promote health communities and prevent chronic diseases. Part of the funds will help to create, update, publicize, and maintain electronic services, and other communication venues to keep the targeted constituency, relevant stakeholders, and the general public up-to-date on systems plus provide data on chronic diseases and health promotion activities.

Global Surveillance CDC uses teleconferencing with state health and laboratory officials to provide the latest information on influenza and how to implement surveillance and infection control. The World Health Organiza- tion coordinates frequent and regular communication between CDC laboratory scientists and scientists from laboratories in Asia, Europe, and elsewhere to share findings, which are then posted on a secure internet site. CDC is funding a cooperative agreement program to prevent non-communicable diseases, adverse reproductive outcomes, injuries, birth defects, developmental and physical conditions in the Latin Amer- ica and the Caribbean region. The funding includes monitoring and assessing maternal and infant health, improving surveillance capabilities, developing interventions and information technology tools, strengthening tobacco control through surveillance and evaluation, performing training, networking, and information exchange, developing indicators and systems to monitor prevention strategies, plus doing economic impact studies on information related to diabetes prevention and control. 82 Federal Activities in Telemedicine, Telehealth, and Health Technology

National Data Systems National Vital Statistics are collected through a cooperative arrangement between the states and the National Center for Health Statistics (NCHS). NCHS operates the National Health Interview Survey and the National Health and Nutrition Examination Survey. The National Ambulatory Medical Care Survey available from NCHS reports that one-quarter of office-based physicians use fully or partially electronic medical record systems. This survey done annually obtains information from physicians who provide direct patient care and practice in the U.S. The survey excluded radiologists, anesthesiologists, and pathologists. The Vaccine Safety Datalink is a collaborative project with AHIP, eight large managed care organizations, and the Immunization Safety Office of CDC.

National Center on Birth Defects and Developmental Disabilities http://www.cdc.gov/ncbddd/index.html NCBDDD is looking to develop a registry tool to be used to identify measures that will aid in the development of national standards of care for patients with spina bifida. Most times caring for individuals with the birth defect is complex and involves different organ systems and different clinical specialists. Using shared computerized reporting and a data processing system will provide for completeness, timeliness, and quality among spina bifida clinics.

Education and Training The Office of Chief of Public Health Practice Program (PHPPO) provides training and performance measurements on public health activities at the state, local, and national level. PHPPO created the Public Health Training Network (PHTN), a distance learning network delivering over 1,000,000 training opportunities to train state distance learning coordinators to help local health workers. The CDC’s 24/7 university-based Centers for Public Health Preparedness providing education through teleconferencing and training programs in disaster management, is now implementing and testing reliable communications, plus offering other hands-on experience. Centers are located in states that have schools of public health, schools of medicine, and other local institutions.

Public Health Law The Public Health Law Program within the Office of the Director uses law as a public health tool. The National Foundation for CDC, HRSA, Robert Wood Johnson Foundation, and the Kellogg Founda- tion have started a Public Health Management Development Network.

Centers of Excellence There are two Centers of Excellence in Health Marketing and Health Communications, and two Centers in Public Health Informatics. The Center of Excellence in Health Marketing and Health Com- munications provides information and educational materials to help people make sound health decisions. The center at the University of Connecticut promotes abstinence, safer sex, and how to reduce drug and alcohol use among youth and young adults. The University of Georgia focuses on the health of the poor in the South and examines responding to health risks. The Center in Public Health Informatics does health technology research. One center at Harvard 83 Federal Activities in Telemedicine, Telehealth, and Health Technology

Medical School is developing computer-based systems to rapidly identify disease outbreaks using patient and other medical records transmitted between physicians and public health officials. Researchers from the Ambulatory Care and Prevention within the Harvard Medical School, Harvard Pilgrim Health Care, the Massachusetts Department of Public Health, Children’s Hospital Informatics Program at the Harvard-MIT Division of Health Sciences Technology, Harvard Vanguard Medical Associates, and other healthcare organizations, are focusing on asthma, flu immunizations in at-risk populations, and sexually transmitted diseases. Another center located at the University of Washington is focusing on public health surveillance and epidemic detection methods, and developing an interactive digital knowledge management system.

National Institute for Occupational Safety and Health http://www.cdc.gov/niosh NIOSH supports the development and demonstration of mine safety and health technology. Mines need reliable and effective communications systems to function in post disaster environments. Systems are needed to track mine workers during rescue operations and to be able to effectively help with health issues. NIOSH is looking to improve the safety of the miner’s health and first responders in terms of wireless communications, miner tracking, mine escape technologies, and developing communication systems that can be used through the earth.

Substance Abuse and Mental Health Services Administration

http://www.samhsa.gov The agency’s electronic health record system has features designed for behavioral health consumers, caregivers, and providers. SAMHSA awarded 55 grant awards totaling $21 million over three years to help states and territories enhance their capacity to record and report on the performance of their mental health services. The grants are to be administered by SAMHSA’s Center for Mental Health Services and a Uniform Reporting System (URS) will be used to ensure program consistency among the grantees. The funding will be used to:

• Report the URS measures including National Outcome Measures • Improve state and local data infrastructure to ensure accurate reporting • Implement data quality initiatives • Develop web-based systems to improve URS reporting

Grantees meeting all of the URS reporting requirements may propose additional activities to work with state and local entities to develop electronic health records and personal health records. In 2009, SAMHSA began to accept applications for the FY 2009 National all Schedules Prescrip- tion Electronic Reporting Act Program Grants of NASPER. SAMHSA plans to award grants totaling $2 million for up to one year. This program provides for grant support to go to states including the District of Columbia to establish and implement or improve state-administered prescription drug monitoring 84 Federal Activities in Telemedicine, Telehealth, and Health Technology

programs in order to ensure that healthcare providers have access to accurate, timely prescription history information to be able to identify patients at risk of addition.

Food and Drug Administration

http://www.fda.gov FDA conducts in-house research to evaluate emerging technologies and their potential public health impact, and conducts research on existing products and technologies that may affect public health. FDA has offices in Beijing, Guangzhou, and Shangri in the Republic of China and hopes to eventually have a presence in five geographic regions to include China, India, Europe, Latin America, and the Middle East. FDA has signed a memorandum of understanding with Department of Defense and the VA to share more information in a more efficient manner. The idea is to have more data on the safety, efficacy, and utilization of drugs, biologics, and medical devices. The agency has proposed amending postmarket safety reporting regulations for three centers. This will require manufacturers and other facilities to submit their reports in an electronic format to be loaded into the MAUDE database. Two rules have been proposed with one rule applying to electronic medical device adverse event reporting and a rule that applies to electronic drug and biologic product adverse experience reporting.

Office of the Commissioner Office of the Chief Medical Officer The Office provides oversight on scientific and planning related operations and shares plans, organizes, directs, coordinates, and evaluates scientific and medical regulatory activities. The Office focuses on risk analysis and risk management, surveillance methods and tools, and understanding adverse events.

Framework for 21st Century Patient Safety Programs FDA has announced a framework for 21st century patient safety programs. Some of the initiatives that are part of FDA’s 21st approach include:

Patient Safety and Automatic Data Collection FDA is working on a national reporting network to report medical errors and adverse events. FDA operates several safety and adverse event reporting programs such as:

• FDA has updated the Adverse Event Reporting System (AERS) to be known as AERS 2. AERS is a software application used extensively by FDA’s safety evaluators to monitor and manage the safety of prescription drugs and is a critical part of FDA’s post market drug surveillance. The system provides data to the Office of Drug Safety, stakeholders, the public, doctors, FOI requestors, the World Health Organization, and other federal agencies. FDA is working on the Modernizing Drug Safety Initiative to provide information on drug safety surveillance and analysis, and is adding detection and tracking tools to the AER or AER 2 System 85 Federal Activities in Telemedicine, Telehealth, and Health Technology

• FDA has established the “Reportable Food Registry as an electronic portal for receive reports when there is reasonable probability that food eaten will cause serious adverse health consequences • MedWatch has mandatory and voluntary reports, safety information on prescription drugs, biologics, medical devices, and dietary supplements • Center for Food Safety and Applied Nutrition Adverse Event Reporting System (CAERS) stores information in a searchable database that can be routed to medical personnel, and can electronically scan patient records and transmit the documents to medical personnel • FDA reviews drugs 18 months after they reach the marketplace. The agency web site (http://www.fda.gov/cder/drugSafety.htm) has information on a variety of safety information concerning prescription drugs. Information on labeling, REMS, postmarket studies, clinicaltrials.gov, quarterly reports, warning letters and alerts, regulations, consumer information, and how to report problems is included on the site • FDA has issued three final guidance documents to develop ways to assess and monitor the risks associated with drugs and biological products in clinical development and in general use. The final documents describe additional safety testing, monitoring and interventions that may be helpful in selected circumstances. The documents address pre-market risk assessment, development and implementation, evaluates risk minimization action plans called RiskMAPS, and identifies good pharmacovigilance practices

FDA Partnerships • FDA has signed an agreement with the Alliance for NanoHealth to establish the FDA- ANH Nanotechnology Initiative. This initiative is a public private partnership to identify scientific and preclinical states of development through clinical stages and then to commercialization to benefit public health. • The Observational Medical Outcomes partnership with FNIH, FDA, PhRMA is conducting experiments to assess the value, feasibility, and utility of observational data to identify and evaluate safety risks and the potential benefits of prescription drugs. Testing will be done on how to create the infrastructure needed to manage the data • The eHealth Initiative-Connecting Communities for Drug Safety Collaboration is partnering with HealthCare System and Regenstrief Institute/Indiana Network for Patient Care to evaluate the value of using electronic health information to detect and evaluate drug safety signals • The Center for Devices and Radiological Health is collaborating with AHRQ to study the adverse outcomes of late cardiac stent thrombosis • FDA and NIH are developing a federal approach to adverse event reporting. Two products will be developed to include an interactive help system to assist with specific data that needs to be submitted, and a prototype to test the web-based portal • FDA is working with Customs and Border Protection, CDC, USDA, VA medical system, to collect data on medication problems as well as with state health groups, and private sector organizations • FDA has worked with NLM to set up “The DailyMed” to distribute up-to-date and comprehensive medication information electronically 86 Federal Activities in Telemedicine, Telehealth, and Health Technology

• FDA’s partnership C-PATH brings FDA, academia, and industry, together to improve testing and evaluate new medicines and medical products on the critical path from the laboratory to patients • FDA’s Center for Biologics Evaluation and Research is collaborating with CDC on the Vaccine Safety Datalink • FDA is partnering with MIT’s Center for Biomedical Innovation to monitor pharmaceutical products and medical devices for the safety and efficacy of new and also well established pharmaceutical products and medical devices • FDA discusses new technologies for combat care and general medical use with the Army Medical Research and Material Command, with the National Cancer Institute, and with NASA to discuss joint technology transfer activities

Cooperative Research and Development Agreements FDA and VHA signed a Memorandum of Understanding that both agencies would share information and expertise related to the review and use of FDA regulated drugs and devices. The goal is to explore ways to enhance post-market medical communication through interagency activities. FDA signed a Cooperative Research and Development Agreement (CRADA) to establish a collaborative project between FDA and DataPharm Foundation to review disseminate drug labeling information. Under the CRADA, FDA provides research recommendations and research oversight, while the DataPharm Foundation evaluates procedures and systems for electronic submission and the distribution of drug labeling.

Medical Devices for Children In 2009, FDA awarded three grants to help to stimulate the development of pediatric medical devices. Children differ in size, growth, and body chemistry, and present unique challenges to device designers. Although the program is administered by the Office of Orphan Product Development, this program encompasses devices used in all pediatric diseases not just rare diseases.

Enhanced Communications FDA wants to be able to identify, validate, and track the authentication of prescriptions drugs. FDA wants to establish an electronic system using RFID technology or other tracking technologies to prevent the counterfeiting, diverting, misbranding or adulterating of drugs, and to identify substandard or expired drugs. FDA requires drug manufacturers to submit prescribing and product information in an electronic format with accurate, up-to-date drug information using standardized medical terminology in a readable accessible format. FDA has adopted SNOMED as the standard computerized medical vocabulary system to be used to electronically code terms in prescription drug labeling, and to electronically code terms in the highlights section of prescription drug labeling.

Internet Pharmacies The agency is working on protecting consumers from illegitimate internet pharmacies that inap- propriately prescribe medications to patients, or sell potentially counterfeited or contaminated drugs. The 87 Federal Activities in Telemedicine, Telehealth, and Health Technology

goal is to cooperate with other agencies on the problem, and upgrade the computer technology that is used to identify, investigate, and prosecute illegitimate internet pharmacies. FDA is also enforcing regulations that require pharmaceutical manufacturers to use RFID technology or any other tracking system to stop drug counterfeiting.

Integrated Data Center FDA has opened an integrated data center at the FDA campus in White Oak Maryland. The facility houses the state-of-the-art laboratories for FDA centers dealing with drugs and biologics, devices, and veterinarian medicine. Ten contractors are going to receive $2.5 billion for IT and data center management services over the next ten years. The ten contractors will compete for data information technology task orders through this contract.

NCTR Center for Toxicoinformatics http://www.fda.gov/nctr Genomic Data Tool http://www.fda.gov/nctr/science/centers/toxicoinformatics/ArrayTrack FDA has a Genomic Tool called ArrayTrack a bioinformatics resource for DNA microarray and systems biology that is able to provide management, analysis, and interpretation of data within a single package. ArrayTrack provides FDA with an integrated solution for managing, analyzing, and interpret- ing microarray gene expression data. Many statistical and visualization tools are available and provides information on genes, proteins and pathways for biological interpretation.

Center for Devices and Radiological Health http://www.fda.gov/cdrh CDRH within FDA is responsible for regulating medical devices and radiation-emitting electronic products used for telemedicine. The CDRH looks to strengthen postmarket surveillance, improve quality systems, do standards development, and research, and look at policies regulating medical software devices that include computerized patient records and hospital information systems. Many devices applicable to telemedicine may be derived from technology developed in the defense, space, or intelligence communities. CDRH established a Technology Transfer Taskforce to provide assistance to the Department of Defense’s Advanced Research Projects Agency (DARPA) and their contractors regarding the premarket approval process for telemedicine devices. The Medical Device Innovation Initiative makes new medical devices more readily available to patients. CDRH is expanding efforts to promote product development, doing research on cutting edge science, reviewing innovative devices, and investigating how to make clinical trials less burdensome. Other CDRH efforts include:

• Collaborating with outside groups on innovative medical devices in critical areas such as in pediatrics • Conducting outreach to improve communications among FDA, industry, patients, and clinicians 88 Federal Activities in Telemedicine, Telehealth, and Health Technology

• Doing laboratory research to improve the development of devices • Implementing a quality review program • Developing an IT system to do better monitoring and tracking of pre-market submissions and post market activities • Expanding the use of outside experts through the Medical Device Fellowship Program to remain current on the latest technological and clinical advances

Medical Devices The “Postmarket Transformation Initiative is able to identify, analyze problems more quickly, and alert the public about potential medical device issues. The initiative focuses on developing an electronic reporting system for adverse medical device events, developing performance measurements to handle issues, developing a unique identifier system, increasing the use of MedSun programs, devising ways to improve information in patient records, improving internal collaboration on post market safety issues, and collaborating on safety issues with professional organizations and the medical device industry. The CDRH is looking at devices used in the home since they have received reports on adverse events happening with medical devices and more of these reports seem to be coming from the home environment. This is due in part to more devices with technology improvements, the shifting reimbursement patterns, and the desire for patients to receive more care in the home. Many devices are being reclassified so that prescriptions are not necessary. Class II and Class III devices are prescription devices and are not directly available over the counter for use by the general public. Prescriptions used in the home are provided mostly by licensed healthcare practitioners. Although manufacturers give more labeling and information, devices that are not labeled for over the counter are not required to be accompanied by training and education for use by non-clinical users. The FDA is looking to see to see how “Unique Identifier Systems” for medical devices may reduce medical errors, facilitate device recalls, and improve medical device adverse event reporting. The number and complexity of medical devices is growing and FDA needs to be able to identify new risks and work with industry and device users. CDRH’s Home Health Care Committee hosted a meeting to help stakeholders discuss safety concerns that are surfacing as patients use medical devices in the home after they leave the hospital. These devices used in the home can range from equipment such as wheelchairs to items like glucose meters, infusion pumps and ventilators. Several meetings have been held with AHRQ, CDC, CMS, CSPS, HRSA, JCAHO, NIDRR, NSF, and the VA to develop cooperative strategies to improve safety and effectiveness for medical devices in the home. The agency is working on the design, development, and evaluation of RF wireless technology in medical devices and looking at the effective use of RF wireless technology in terms of wireless coexis- tence, performance, data integrity, security, and electromagnetic compatibility.

Standards CDRH is developing standards to characterize and evaluate medical devices, that apply to equipment standards, process standards, and standardizing nomenclature. CDRH has encouraged collaboration between manufacturers of diagnostic imaging equipment represented by the National Electrical Manu- facturer Association with the clinical community represented by the American College of Radiology. 89 Federal Activities in Telemedicine, Telehealth, and Health Technology

Together they are working on a standard for the interconnection of diagnostic imaging systems. CDRH databases include information on premarket notifications, premarket approvals, medical devices, product classifications, and standards.

Sentinel Network FDA is creating a virtual, integrated electronic “Sentinel Network” to enable FDA to query a broad array of information to be able to identify possible post-market adverse events. FDA will be able to monitor the performance of a product throughout its entire life cycle. The Sentinel System will be created through public private partnerships and will capitalize on existing large electronic claims and medical records data sources maintained by private and government entities that agree to participate in this nationwide effort. FDA awarded six contracts to develop the system. The contracts went to Pragmatic Data LLC in Indianapolis ($98,000), Harvard Pilgrim Health Care, Inc. ($98,000), Booz Allen Hamilton Inc., ($98,532), Outcome Sciences, ($99,564), Group Health Cooperative Center for Health Studies, $(98,000), and IMS Government Solutions, Inc. ($92,020). In 2009, FDA posted an announcement seeking more information for Sentinel planning and development. The agency is looking to build upon models already developed by other agencies and from ongoing contractual work. FDA plans to support test queries, methodology development, testing, and implementation of support projects, and proof of concept development.

Center for Drug Evaluation and Research http://www.fda.gov/cder Office of Oncology Drug Products The Office of Oncology Drug Products reviews drugs and therapeutic biologics to diagnose, treat, and prevent cancer, which includes drugs and certain therapeutic biologics used in medical imaging. The office consults with the Center for Biologics Evaluation and Research, the Center for Devices and Radio- logical Health, and the Center for Food Safety and Applied Nutrition.

Training and Education FDA keeps scientists up to date on emerging technologies by providing a joint training program focusing on technologies. The first of these courses brought together more than 30 FDA field investigators and scientists to a Merck manufacturing plant to look at state-of the-art sterilization methodologies.

Advisory Committees CDRH has a number of advisory committees to provide independent, professional expertise and technical assistance on the development, safety, effectiveness, and regulation of medical devices and electronic products that produce radiation. One of the committees, the Medical Devices Advisory Com- mittee consists of 18 panels in the medical specialty areas. 90 Federal Activities in Telemedicine, Telehealth, and Health Technology

Indian Health Service

http://www.ihs.gov ARRA funds provide $500 million to IHS with $85 million for health information technology. The health information technology funds will go for telehealth services and infrastructure requirements. Ap- proximately 20% of the funds will be used for hardware acquisition to modernize infrastructure relating to security, networking communications, and health IT. The Resource and Patient Management system will be modernized. The Indian Health Service provides health services to approximately 1.9 million of the nation’s American Indians and Alaska natives belonging to 560 federally recognized tribes in 34 states. Care is provided directly to 49 hospitals, 283 health centers, 162 Alaska village clinics, and 154 health stations. IHS contracts with hospitals and healthcare providers outside of its own network, and funds 34 urban Indian health organizations to provide access to care for Indians in urban areas. Some of the provisions in the Indian Health Care Improvement Act will help the Native Ameri- can population find help for diabetes, chronic liver disease, and other medical problems. Some of the provisions in the Act would create a Indian Youth Telemental Health Demonstration Program, expand the Indian health professional workforce, expand cancer screening, improve monitoring for infectious diseases, improve current diabetes screening, protect privacy, fund urban Indian youth treatment centers, and encourage states to help Indians on or near reservations.

Telehealth and Telemedicine The stimulus package funding will provide $85 million to be used for health IT and telehealth technologies within the Indian Health Service. Presently, IHS and Tribal facilities work with over thirty different types of telemedicine clinical services. The Indian Health Service funds telemedicine and telehealth equipment for use on remote Indian reservations and small communities. New telemedicine systems increase access to remote patients by consulting on difficult cases, doing cardiac monitoring, tracking vision degeneration in diabetic patients, performing x-rays and ultrasound interpretations, and providing telepsychiatry.

Some of the Telemedicine and Telehealth Projects • Patients with diabetes receive remote diagnosis and management of diabetic eye disease via the IHS Joslin Vision Network. • Children with ear problems receive care from ENT surgeons at the Alaska Native Medical Center in anchorage via teleconsultations. • In southern Arizona, patients with heart failure have access to cardiologist case management services via home telehealth • Mammography interpretations are provided using telemedicine links from Navajo Area IHS and Tribal facilities to a Breast Center in Tucson • Telemental health service is a growing part of many rural Indian health programs. • Confidential and parent consented telemental services are provided to high school students 91 Federal Activities in Telemedicine, Telehealth, and Health Technology

IHS is involved in telehealth clinical activity and developing new clinical telemedicine applications. IHS is involved in three national telehealth programs such as the IHS/JVN programs, IHS/OVC Child Abuse Project, and the Native American Cardiology Program. Mature telehealth applications pre- dominate in radiology, psychiatry, dermatology, and ophthalmology. Other clinical applications include primary care, perinatology, telepharmacy, general surgery, child advocacy, burn and wound care, pediatric specialty care, oncology, nephrology, and neurology. Future applications include developing eICUs and Virtual Centers of Excellence, and developing interoperability demonstration projects as part of the NHII. Other telehealth activities include developing broadband networks in many states and regions, providing distance learning opportunities and offerings, and using telehealth technologies for administrative meetings, program planning, public health information needs, and community health outreach. The Indian Health Board provides advice and technical assistance to the IHS, with information based on tribal input through a broad-based consumer network involving the Area Health Boards with representatives from each of the 12 IHS areas. Under the agreement, the board communicates with tribes and tribal organizations on health issues, disseminates healthcare information, and expands access for American Indians and Alaskan natives.

Tribal Epidemiology Centers IHS is funding a Tribal Epidemiology Center in California to help the AI/AN urban population and will set up Tribal Epidemiology Centers in all of the 12 IHS Administrative areas.

Grants, Contracts, and Collaborative Agreements Tribal Management Grants are awarded as part of existing Indian Health Programs, to further develop and improve management capabilities, do program planning evaluations, and develop necessary management systems. Any federally recognized Indian Tribe or Tribally sanctioned tribal organization is eligible to apply for a grant. The IHS Urban Indian Health Program awards contracts and grants to 34 urban health programs operating at 41 sites located in U.S. cities. The program is funded under Title V of the Indian Health Care Improvement Act. Approximately 100,000 American Indians Health do not have access to hospitals, health clinics, or contract health services administered by the IHS because they do not meet eligibility criteria or they reside outside of the IHS and tribal service areas. Another 49,000 AI/AN use Title V programs in cities that are located in Indian Health Service or tribal service delivery areas. The grants and contracts are awarded for health promotion and disease prevention, to provide dental services and comprehensive primary care services, to provide information, to help with substance abuse, to provide behavioral health services, to conduct immunization programs, and to help with HIV activities. The National Native American Emergency Medical Services Association (NNAEMSA) has signed a cooperative agreement with IHS to disseminate information and education regarding emergency medical services and to establish an annual conference. The goal is to establish links with other national Indian organizations, and professional EMS groups.

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Information Technology The Indian Health Service information technology infrastructure has a full range of capabilities, from storing, retrieving, aggregating and evaluating patient medical records, to transferring complex medical images through satellites, to sending data to specialists in centers of excellence. The National Patient Information Reporting System provides a broad range of clinical and administrative information to managers in all levels of the Indian healthcare system and as of 2009 is certified by CCHIT. The System serves as an agency-wide statistical information system, as a third-party billing system, and warehouse for health data for IHS providers. Data is moved for over 2.2 million patient encounters at 293 IHS and Tribal healthcare facilities in 35 states and supports enhance care-coordination capabilities. The Resource and Patient Management System (RPMS) is used for more than 60 integrated patient- based administrative and clinical software programs. The Clinical Reporting System is an RPMS software application designed for national reporting as well as local and area monitoring of clinical performance measures. CRS produces from local RPMS databases a printed or electronic report for 300 plus clinical performance measures representing 55 clinical topics. The system is certified by CCHIT. The system collects patient data from the IHS electronic record system from 182 clinics and other organizations, plus generates reports. The data is available to nurses, physicians and other providers in IHS, plus reports go to Congress and OMB. The EHR incorporates the RPMS so that the provider will have patient information available via “point and click” and the user does not have to log in and out of separate RPMS applications to retrieve the different types of data. The IHS EHR system is based on the VA’s EHR system, but the IHS system does not have the capacity to store images in patient records. The IHS is adopting and testing the VA’s VistA Imaging System. IHS is sharing the RPMS with NASA’s Office of the Chief Health and Medical Officer. NASA wants to use the system’s integrated suite of software applications for patient and population level clinical and administrative data. NASA is developing state-of-the-art approaches to recording and assessing occupational health issues. The IHS uses Electronic Dental Record (EDR) System with software provided by Dentrix Dental Systems, Inc. The system software to be integrated with the IHS RPMS will provide an electronic dental record for approximately 300 IHS, Tribal, and Urban dental programs and provide service to 1.8 million American Indians and Alaska Natives. An integrated electronic case management system called iCare automates clinical data. The system provides caregivers with an integrated medical history on each patient and provides case managers and other healthcare specialists with various aggregate views of data by disease, by providers, and by the population served. The RPMS iCare web site has been developed at (http://www.ihs.gov/CIO/ca/icare/index. asp).

Alaska Native Tribal Health Consortium http://www.anthc.org The Alaska Native Tribal Health Consortium (ANTHC) serves over 200,000 Alaska Natives and oversees the Alaska Federal Health Care Access Network (AFHCAN). Since 1998, the AFHCAN has awarded $31 million to connect 235 rural villages in Alaska through a statewide telemedicine system. 93 Federal Activities in Telemedicine, Telehealth, and Health Technology

Using state-of-the-art technology and equipment, member organizations send medical images, health information, and voice data to regional hospitals for remote diagnosis and consulting. The ANTHC also has a teleradiology project underway to link ten regional hospitals throughout the state with 40 remote clinics, transmit images via teleradiology. The top needs in the Native community concern cancer, chronic disease management especially diabetes and cardiovascular diseases, prevention referring to tobacco and drug use, suicide, domestic violence, behavioral health issues such as substance abuse and mental health, elder care, and oral health. Successful local programs link clinical services to community wellness and disease prevention activities such as:

• The Indian Health Service Child Abuse Project does medical evaluations on children that are mistreated. The information is available for physicians, nurse practitioners, and physicians who work with American Indians and Alaskan Natives. The project has equipment, resources, and training for peer review on using telemedicine • The Warm Springs Health and Wellness Center in Warm Springs Oregon targets populations such as the elderly, women, and children • The Arizona Indian Health Service in Window Rock Arizona provides help for rural populations using a number of facilities • The Native Project an urban Indian program in Spokane Washington operates an outpatient program for substance abuse and mental health treatment for adolescents • The Phoenix Area Initiative resulted in wellness teams in nine local service units to provide programs to address all aspects of wellness for their communities • IHS is active in teledermatology with waiting periods for dermatology consultations short- ened from four weeks to one or two days • IHS is active in telephsychiatry is helping tribal facilities and school clinics have access to outside specialists

Partnerships The Indian Health Service and NIH have a partnership with American Indians and Alaska Natives as participants in research and training. The partnership began when the Indian Health Services and the National Institute of General Medical Sciences (NIGMS) jointly issued an announcement seeking applications for Native American Research Centers for Health. Originally, the NIGMS provided $2 million each year for four years to fund the program with NIH providing additional amounts. The proposals were of such high quality, that the NIGMS decided to provide the Indian Health Service with an additional $1.5 million per year. One grant was awarded to the Northwest Portland Area Health Board to improve research skills for Indian health professionals and to study the use of evidence-based medicine to improve healthcare. An- other grant was awarded to the Alaska Native Tribal Health Consortium to do various research projects dealing with diabetes, disabilities in children, telemedicine, disease prevention, and nutrition.

Health Online Information The agency has online information for a comprehensive collection of health information and histori- 94 Federal Activities in Telemedicine, Telehealth, and Health Technology

cal health data on the American Indian and Alaska Native population. Two databases, the Native Health Research Database (NHRD) and the Native Health History Database (NHHD) were developed through a partnership between the Indian Health Service and the University of New Mexico. The NHRD provides bibliographic information and abstracts for health-related articles and resource documents. The database features some online, full text documents and direct links to health and wellness web sites as well as to Medline citations focusing on the Indian population. The NHHD provides users with access to historical health information focused on the American Indian and Alaska Native population. The database includes early descriptions of diseases and healing practices.

Health Quality Website http://www.ihs.gov/NonMedicalPrograms/quality IHS has launched a website with information on the quality of care provided to American Indian and Alaska Native patients. This effort was undertaken with the VA and DOD and reports on diabetes, immunizations, pneumonia, asthma, and stoke. In 2009, two other immunizations and three cardiovascular disease related measures were added.

Specific Programs X-ray Scans The Indian Health Service has placed radiographic readers in 10 hospitals and clinics on Navajo reservations. The x-rays are scanned and transmitted to other Navajo area hospitals or to the University of New Mexico Medical Center where consulting radiologists can provide a diagnostic report.

Mammography The Indian Health Service uses a digital mammography unit called the Mobile Breast Care Center (MBCC) to help American Indian woman. The Indian Health Service and tribal health care providers use the MBCC at Tuba City, a remote site on the Navajo reservation in Arizona. The MBCC is a key component of the Mobile Digital Telemammography Project initiated by DOD and HHS to address the barriers to sustaining critical health care services in underserved areas. The MBCC uses the most advanced technology for breast cancer detection that includes onsite patient screening, diagnosis, and education, all during one visit. MBCC is based on technology developed by GE in their Corporate Research and Development Center. The MBCC captures images by using detector plate visualization and the computer is able to enhance suspicious areas within the breast. After full- field mammograms are obtained, the digital images are immediately transmitted to a medical center for diagnosis and evaluation. Before leaving the center, the patient has a private consultation with a member of the healthcare staff to discuss the results and the appropriate follow-up care. Patient education is also provided during the visit using the internet or video and audiotapes.

Cardiovascular Disease Cardiovascular disease has become a major source of disability and hospitalizations are increasing and resulting in more inpatient and outpatient procedures with more people dying in the American Indian community. The Indian Health Service and the tribes see the need for aggressive treatment and prevention activities. 95 Federal Activities in Telemedicine, Telehealth, and Health Technology

The Native American Cardiology Program (NACP), collaborating with the Navajo, Phoenix and Tucson areas of the Indian Health Service, is based at the University of Arizona. The program extends to the University Medical Center, the Flagstaff Medical Center, Southern Arizona VA Healthcare System, as well as to Native American Tribes and communities. The program promotes cardiovascular health and wellness through state-of-the-art treatments, education, and prevention. The program has hospitals and clinics in Arizona, Nevada, Utah, and parts of New Mexico and Cali- fornia. The NACP provides multiple services, including both telephone consultations and telemedicine services. Cardiology clinics uses real-time telemedicine, two-dimensional and color tele-echocardiography, as well as stress echocardiography tests provided at a distant field site. Multiple teleconferences such as the Indian Health Service Cardiology annual meeting are held.

Diabetes Program The Indian Health Service Diabetes Program has launched two programs. The Model Diabetes Pro- gram consists of 19 comprehensive projects to develop expertise in the prevention and treatment of diabetes and to share expertise with other tribes and communities. The other program, the Special Diabetes Program for Indians is a network of 333 grants for multi-faceted diabetes treatment and prevention projects that rely on community-based efforts. The Indian Health Service is working with the Joslin Vision Network in their teleophathalmology program to provide remote imaging to detect diabetic retinopathy.

Mental Health IHS focuses on mental health screening and how to practice primary prevention especially for depression, researching the use of effective treatment modalities, and now uses a behavioral health software package to improve documentation for mental health problems.

Chronic Diseases Innovations in Planned Care Program Innovations in Planned Care Program helps prevent diseases, treat behavioral health, and provides better chronic care. The program provides coordinated care for Tribes and communities by using strong care teams to improve the care of chronic conditions like diabetes, cancer, arthritis, and asthma. Fourteen Tribal, IHS, and urban pilot sites of the initial IPC have been working with support from the Institute for Healthcare Improvement. The project is expanding from fourteen to forty teams.

Research Native American Research Centers for Health Grants http://www.ihs.gov/medicalprograms/research/narch.cfm The NARCH Initiative provides grants to develop partnerships between AI/AN Tribes or tribally- based organizations such as the National Indian Health Board and Area Health Boards, and institutions. These partnerships are in place to conduct academic level biomedical, behavioral, and health services research to be competitive for securing NIH funding.

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Future and Ongoing Activities Electronic Health Records will be deployed to more sites, telemedicine capability will be incorporated with Vista Imaging using a high speed data network, a national data warehouse will be provided, a new management system will be deployed, new secure systems will be developed, and there are plans to expand training opportunities. 97 Federal Activities in Telemedicine, Telehealth, and Health Technology

Department of Defense

http://www.defenselink.mil As part of the Recovery Act, DOD has identified over 4,000 construction, facility repairs, and research projects that will be undertaken. ARRA included $7.4 billion in Defense related appropriations which account for less than 1 percent of the total $787 billion stimulus.

Health Affairs http://www.health.mil The Department of Defense (DOD) is using telemedicine, telehealth, and health IT technology to provide direct healthcare delivery to the military. DOD has an advantage in using technology for medical use, since the defense community is already heavily involved in information and communication technologies. DOD realizes that the medical and healthcare delivered to military personnel is rapidly changing with rising costs, and therefore medical treatments need to be modified and made efficient to meet these changes. DOD also understands that the 21st century is a new world with terrorism and bioterrorism, with new discoveries in genetic research, technological advances in biomedicine, and that all of these advances can have an effect on treating the military.

Military Health System http://www.health.mil The Military Health System (MHS) is a worldwide network of military hospitals, health clinics, DOD’s private sector health business partners, and the Uniformed Services University of the Health Sciences. MHS operates TRICARE. MHS in their Health Science and Force Optimization Program oversees the Clinical Investigation Program to improve patient care. The program also provides DOD healthcare providers with access to information on new and emerging health and medical technology innovations, and studies deployment health issues, and partners with other agencies on agriculture security. The Executive Information and Decision Support Program Office within MHS uses information and tools to manage healthcare and provides a centralized data store for MHS. The Information Management and Information Technology Program oversees system requirements and the acquisition and worldwide deployment of software/hardware systems. The Joint Medical Information Systems Office supports healthcare operations through the design, development, test, evaluation, and deployment of medical information systems. MHS has merged the Clinical Information Technology Program Office (CITPRO) and the Theater Medical Information Program –Joint (TMIP) program to create the Defense health Information Manage- ment System (DHIMS). The Defense Medical Logistics Standard Support (MLSS), Executive Informa- tion Decision Support (EIDS) and the Resources Information Technology Program Office (RUITPO) have merged into the Defense Health Services Systems (DHSS) office. MHS has implemented a disease management initiative across all three managed care regions to focus on asthma and congestive heart failure, but the program also addresses diabetes, cancer, COPD, plus depression and anxiety disorders. The MHS has implanted a finance system, a pharmacy formulary, 98 Federal Activities in Telemedicine, Telehealth, and Health Technology

and other business practices to improve efficiency and effectiveness. The MHS web site is available for military and civilian healthcare professionals to submit questions, share ideas, and recognize peers interactively. The MHS Health Portal is a tri-service web-based tool that generates detailed action lists, looks at clinical preventive services, and manages diseases for enrolled beneficiaries. Additionally, the Portal allows Medical Treatment Facilities to track and compare quality of care, access to care, and beneficiary satisfaction against national Health Plan Employer Data and Infor- mation set standards. EWRAS an IT initiative in the MHS works with service medical departments to define requirements. EWRAS delivers real-time scheduling through TRICARE, monitors and records a patient’s progress from surgery to recovery, promotes optimal health status for individuals and populations, and enables seamless admissions, discharges, and transfers throughout the military health system. The TRICARE Management Activity with the Army, Navy, and Air Force make up the office staff of the Military Health System, Office of Transformation. The office provides policy guidance and directions on base realignments and closure actions, medical readiness reviews, and makes recommendations to working groups. The Advanced Technology Integration Center supports the MHS Program Management offices and the Uniformed Services medical department chief information officers. ATIC provides six information technology services for MHS and the military services. The MHS AHLTA-Dental has consolidated Tri-Service dental records into a single secure electronic resource. The system provides worldwide access to integrated medical and dental records and provides diagnoses with real-time access to the information. The system also provides for training courses on the internet, classroom training, and training in the dental facility.

Military Infectious Diseases Research Program The Military Infectious Diseases Research Program works to protect against infectious diseases with the research focusing for the most part on the military. The Military Health System has combined several of the health IT systems and staff to establish the Center. The center collects, analyzes, interprets, reports on data, provides timely information, responds to disease outbreaks by monitoring health events, and provides training and education on health surveillance. The program researches wound infections to develop and evaluate devices, technologies, and treatments to prevent and treat wound infections in combat casualty injuries.

Biological Research and Defense DOD’s responsibilities include chemical and biological defense for the country, and developing technologies to use for medical surveillance to identify diseases. Technologies developed for mobile laboratory specimen analysis includes rapid and automated dissemination, recording and archiving of medical surveillance reports and analyses, rapid handheld screening assays and immunoassays, specimen processing, and gene amplification. The Biological Defense Homeland Security Support Program looks at the possibility of a biological- related incident in an urban area and how to reduce casualties and minimize disruption to infrastructures. The program provides biological detection capabilities, medical surveillance systems, environmental sensors, and communications systems integration. 99 Federal Activities in Telemedicine, Telehealth, and Health Technology

DOD through the Base Realignment and Closure (BRAC) process will make changes that will affect the medical system, and create six new centers of excellence for biomedical research. The centers will include the Joint Center of Excellence in Battlefield Health and Trauma at the Brooke Regional Med- ical Center, the Joint Center of Excellence in Infectious Disease Research at the Forest Glen Complex in Maryland, the Joint Center of Excellence for Aerospace Medicine Research at Wright-Patterson Air Force Base, the Joint Center of Excellence in Regulated Medical Product Development and Acquisition at Fort Detrick, Maryland, the Joint Center of Excellence in Biomedical Defense Research at Fort Detrick, Maryland, and the Joint Center of Excellence in Chemical, Biological Defense Research, Development and Acquisition at the Aberdeen Proving Ground, in Maryland.

Advanced Systems and Concepts Demonstrations http://www.acq.osd.mil/actd The Advanced Concept Technology Concepts Demonstrations Program uses mature and maturing technologies to solve military problems. The Office of Technology Transition is responsible for policies and establishing and managing programs to take advanced technologies from R&D to weapons systems.

Theater Medical Information Program-Joint http://www.ha.osd.mil/peo/tmip/default.asp The DOD Theater Medical Information Program electronically transmits and sends data to the interim theater database at the Joint Task Force commander level. Physicians are able to document patient’s injuries using a pull down menu application installed on the care provider’s handheld computer. The system serves as the medical component of the Global Combat Support System. TMIP works in the following areas:

• Command and Control—Analysis of medical sustainability and supportability, medical situational awareness and medical surveillance • Health Care Delivery—Medical encounter documentation, immunization management, and post deployment survey capability • Medical Logistics—Re-supply inventory and assemblage management, management of blood/blood product inventories, and product identification

After the tour of duty is over, the patient’s medical information is electronically transferred to the CONUS-based clinical data repository for incorporation into the patient’s computer-based patient record. Over the next several years, TMIP-Maritime hopes to institutionalize its suite of products as the Navy’s standard for documenting all patient medical care. Within the next few years, TMIP-Maritime products will be fielded to all ships, submarines, and operational Navy Medical shore commands as they become available. The TMIP-USMC plans to field systems to all Marine Corps Medical commands starting in FY 2010. 100 Federal Activities in Telemedicine, Telehealth, and Health Technology

Military Wide Systems Defense Knowledge Online Portal DOD has created the Defense Knowledge Online (DKO) portal to provide a single entry point for information soldiers and commanders. The Army Knowledge Online (AKO) provides employees, retir- ees, and families access to the Army’s web tools. AKO is composed of a board of directors with chief information officers from all the military services along with technical representatives acting as advisors.

Global Expeditionary System The Global Expeditionary System (GEMS) sponsored by the Air Combat’s Office at Langley AFB is a medical watchdog for deployed troops to detect and prevent injuries and disease. Patient data is electronically analyzed for early signs of disease or bioterrorism. The system does syndromic surveillance and provides near real-time analysis of the data. The GEMS can work with raw data and sends information immediately and automatically to public health commissions. Other communicable diseases are also surveyed and reports are developed. The system is used in almost all deployed AE Expeditionary Medical units and used in the Air Force Forward Theater Medical Information Program.

GEIS DOD-GEIS supports global surveillance, training, research, and response to emerging infectious disease threats, and carries out preventive programs to reduce or eliminate the risk of infectious diseases.

ESSENCE Defense military health uses the Electronic Surveillance System for Early Notification of Com- munity-based Epidemics (ESSENCE) to help detect both naturally occurring outbreaks of disease and potential bioterrorism attacks. The system can link medical data with geographic information systems to track the spread of symptoms. After 9/11, ESSENCE was expanded to include outpatient information from hundreds of Army, Navy, Air Force and Coast Guard medical facilities around the world. To detect potential epidemics or bioterrorist attacks, medical data provided by ESSENCE is examined with older data going back several years. Mathematical formulas are used to see whether a comparison is expected. For example, a sharp spike in the number of people being treated for gastrointestinal disorders could indicate the beginnings of an epidemic. DOD maintains a companion medical database program ESSENCE II to gather outpatient medical information from stateside civilian hospitals, and works in partnership with the Johns Hopkins Applied Physics Laboratory and several other groups. In the case of bioterrorism, both anthrax and small pox can masquerade as the flu in the early stages after exposure, so if abnormal incidences of disease are observed, than an alert is provided to public health officials. The system includes data from Washington D.C, Baltimore, and 12 counties in Maryland and Virginia. DOD has contributed six million to the project along with one million from Maryland.

Defense Medical Epidemiology Database The Reportable Medical Events System (RMES) summary statistics are accessible through the Defense Medical Epidemiology Database. RMES automatically transmits data for 70 reportable medical 101 Federal Activities in Telemedicine, Telehealth, and Health Technology

events to the Defense Medical Surveillance System. The system warehouses the data, analyzes the data, interprets the data, and provides summary reports.

Defense Occupational Environmental Health Readiness System The Defense Occupational Environmental Health Readiness System (DOEHRS) provides data on disease outbreaks and injury trends and helps the military make better battlefield decisions. The system links to the AHLTA system, the DOD Hazardous Substance Management Systems in the Environmental IT Management Program, and adds data to the Theater Medical Information Program. DOEHRS-IH was created to store and analyze information on occupational exposures, workplace environmental monitoring, personal protective equipment usage, work practices, and employee health-hazard educational data.

Defense Medical Surveillance System The DMSS is a deployment health quality assurance program and provides centralized periodic reports. DMSS maintains a centralized database and provides weekly reports on post-deployment health assessments with monthly reports on pre-deployment health assessments. Post-deployment reports have data on health status, medical problems, mental health and exposure concerns, blood samples, and referrals for post-deployment care. Information and reports are provided on service deployment health quality assurance programs.

Theater Enterprise Wide Logistics System TEWLS is a joint medical logistics automated system to provide support at the theater level and is fielded to all combatant commands. This system will be incorporated into the joint medical logistics automated program called Defense Medical Logistics Standard Support System.

JMeWS JMeWS is an automated healthcare monitoring and tracking system to provide online near real-time medical situational awareness for forward deployed forces. JMeWS provides the status of the medical units in theater based on reports sent to JMeWS from each medical unit.

Joint Medical Logistics Automated System The joint medical logistics automated system provides support at the theater level and will be incorporated into the joint medical logistics automated program called the Defense Medical Logistics Stand Support System.

TMIP Composite Health Care System Cache (TC2) TC2 provides documentation for inpatient healthcare and ancillary services, for order entry, and for reporting results in the deployed environment. TC2 offers inpatient management, laboratory, radiology, pharmacy ordering capabilities, and enables users to schedule outpatient clinic radiology procedures.

Theater Medical Data Store (TMDS) Information from the theater medical systems are transferred to the TMDS which serves as the theater database for collecting, distributing, and viewing service members pertinent medical information. 102 Federal Activities in Telemedicine, Telehealth, and Health Technology

Joint Medical Analysis Tool (JMAT) JMAT is an application that provides Joint Medical Planners and decision-makers with a tool to support crisis action planning.

DMLSS Customer Assistance Module (DCAM) DCAM is a medical logistics ordering tool that allows operational units to monitor medical supplies.

Patient Movement Items Tracking System (PMITS) PlexusD PMITS PlexusD tracks the storage of PMI and supports moving critical patient movement equipment.

Aeromedical Evacuation System (TRAC2ES) TRAC2ES monitors and tracks patients leaving theater via Air Force aero medical evacuation. The system provides information on incoming and outgoing flights.

Expeditionary Framework (EF) EF provides a messaging service to TMIP-J applications to allow electronic health records and other medical information to be transmitted from the theater to CONUS repositories. The system works in environments with low or interrupted communications.

SNAP Automated Medical System (SAMS) SAMS is an automated multi-user medical support application to help improve naval healthcare by tracking service member’s documents and reports.

DOD Medical Workstation The DOD Medical Workstation monitors troops, in Korea and Japan and the Pacific theater use the system to monitor the health of troops and medical treatment facilities capabilities. The system looks for health trends and data analysis as well as medical treatment facilities locations, equipment, supplies, blood supplies, and personnel.

Joint Patient Tracking System The JPTA system provides information on the status and location of wounded soldiers. The Joint Theater Medical Information Program System uses handheld devices given to field medics with the information going to a common repository.

Joint Theatre Trauma Registry The Joint Theater Trauma Registry, a medical database pulls together medical records for wounded soldiers which includes both pre-hospital care and subsequent care in CONUS. The JTTR has the most comprehensive picture of war wounds ever assembled. By combining the JTTR with other personnel 103 Federal Activities in Telemedicine, Telehealth, and Health Technology

and operational databases, the information will help develop improvements in soldier personal protective equipment and vehicle designs. Software has been upgraded to send medical information from the battlefield to a worldwide database.

Armed Forces Health Longitudinal Technology Application (AHLTA) http://www.ha.osd.mil The Armed Forces Health Longitudinal Technology Application (AHLTA) is the military computer- based patient record to generate, maintain, and provide secure online access to a comprehensive legible health record for all preventive care, illnesses, and injuries that are treated at any military treatment facility. Providers use the information in AHLTA to optimize individual patient care decisions, develop evidence-based clinical practice guidelines, identify population trends and patterns, deploy real-time clinical practice guidelines, expand health care research, and identify best practices. Phase 1 was completed with 55,000 personnel fully trained. Phase 2 now provides for ordering eyeglasses and has dental charting. Phase 3 and 4 is expected to be fully operational by 2014. The system views and updates patient’s histories, orders prescriptions or x-rays, makes a diagnosis, and codes the visit. AHLTA merges commercial off-the-shelf applications on the market into a single integrated system capable of worldwide deployment both in fixed facilities and in the field environment as part of the theater medical information program. Other systems interact with AHLTA such as CHCS (MHS legacy electronic medical system), VistA, the Pharmacy Transactions Service (imports medical information from sources outside MHS) and Eccen- tris (a commercial inpatient EMR system purchased by MHS hospitals.) At the Naval Medical Center in San Diego, errors have been reduced from 30% to 5% and the system has reduced documentation time by about 13 minutes per patient. NMCSD plans to adopt a voice recognition system that would allow providers to dictate notes electronically. The AHLTA system is deployed across 25% of the MHS, 40% of AMEDD, and used at 87 of 140 planned MTFs. The Clinical Data Repository is operational with electronic clinical records for over 7.5 million beneficiaries. AHLTA has processed over 15,000 outpatient encounters and is currently processing over 75,400 patient encounters per workday in 461 military clinics around the world, schedules 50 million outpatient appointments annually, fills 70 million prescriptions, and analyzes 42 million lab tests annually. Eventually, AHLTA, a one billion dollar system, will be used at 139 hospitals and 500 clinics with 156,000 users. Providers in the field are using a portable field version of AHLTA called CHCS II-T which transfers care information to the Joint Medical Workstation (JMeWS) rather than directly to the CDR. This is done for various security and force health protection surveillance reasons, and then transfers the data to the CDR via the JMeWS-CDR. Teledermatology consultations resulting in more than 50 avoided airlift medical evacuations has saved $1 million plus additional costs in the telecardiology program at the Brooke Army Medical Center in San Antonio Texas. Goals are to work with the VA to modernize legacy systems, provide for ancillary order entry and results retrieval, improve patient documentation, and enhance data exchange. 104 Federal Activities in Telemedicine, Telehealth, and Health Technology

AHLTA Warrior The TMIP-J has released an upgrade to its medical software known as AHLTA Warrior. This allows doctors on the battlefield to view a patient’s complete electronic health record that is stored stateside in the AHLTA Clinical Data Repository. AHLTA Mobile provides access to reference materials, and diagnostic and treatment decision support tools.

AHLTA Theater AHLTA Theater extends the electronic medical record (AHLTA) capability. The system enables healthcare providers to document care, order labs, and store medical data until communications are available, and then the data is sent to the Theater Medical Data Store and Clinical Data Repository. The Certification Commission for Healthcare Information Technology announced that the DOD product AHLTA Version 3.3 is pre-market, conditionally CCHIT Certified, and meets the CCHIT ambulatory electronic health record criteria. AHLTA and VistA are sharing data. The FHIE now sends clinical data on separated service members to the FHIE data repository where the VA clinicians can use the data. BHIE interfaces with ALHTA’s TMDS using WSDL in the battlefield to provide information for the continuity of care for injured soldiers. VA clinicians have access to viewable data. There is bidirectional data sharing between AHLTA (CDR) and VistA (HDR).

Global Data Synchronization Network The Network provides for the secure exchange of healthcare suppliers product information. By using GDSN, DOD hopes to improve efficiencies throughout the $200 billion healthcare supply chain and have consistent data on items in their systems at the same time. These efforts are being supported by the Coalition for Healthcare e-Standards, VA, and healthcare manufacturers.

Laptops in the Theater The medical and dental clinical information system provides data on laptops in the theater. Software helps field medics, nurses, and physicians do patient admissions, scheduling, obtain laboratory results, use e-pharmacy, and do radiology procedures. The system includes an Electronic Information Carrier which moves information along with the individual soldier so the current healthcare provider to be able to see a complete record of care.

Pandemic Flu Response DOD funds millions for the pandemic influenza preparedness and response program at the Univer- sity of Texas Health Science Center at Houston. The program called “TxShield” is a multidisciplinary program to conduct basic and clinical research on public health intervention, and focus on potential pandemic flu prevention and response. Funding was also awarded to the Texas Training and Technology for Trauma and Terrorism (T5) program which is the successor to the DREAMS program. T5 develops and tests telemedicine and telecommunication technologies featuring real-time remote monitoring of patients. 105 Federal Activities in Telemedicine, Telehealth, and Health Technology

Psychological Health National Center for Telehealth and Technology (T2) The T2 Center is a component within the Defense Centers of Excellence (DCoE) program. The Center researches, develops, evaluates and deploys new and existing technologies. The Center’s studies involve psychological health and traumatic brain injuries, but the center is also involved in coordinating innovative technology applications to use for suicide surveillance and prevention, developing online behavioral health tools, providing mental health applications, and developing telepsychological health programs. The Center is working with virtual reality mental health applications to treat psychological health and TBI. The Center’s Innovative Technology applications program is doing research and increasing the number of providers trained in VR. Future plans include using VR to support pre-deployment psychological resiliency, conduct TBI assessments through VR, and expand access to care through virtual worlds. Future plans also include increasing integration across DOD, sub-specialty clinic customization, DoDSER integration, and AHLTA connectivity. The Center’s Automated Behavioral Health Clinic offers a standardized, automated check-in process for mental health clinics that treat service members or veterans. The system used is a software system custom tailored to the business practices of military behavioral health clinics. The web site (www.afterdeployment.org) posts information focused on post-deployment problems. The web site’s project office is located at the Madigan Army Medical Center in Fort Lewis and is a project led by the T2 Center. The site enables web tools to be provided 24/7 access anywhere an internet connection is available and the materials can be used anonymously. The web site helps military personnel do self-assessments on their mental health problems such as depression, bipolar disorders, alcohol abuse, PTSD, and anxiety. DOD is studying the health effects of deployments, with service members and has completed more than one million pre-and post-deployment health assessments. Nearly 90 % of the information is collected and transmitted to the U.S. electronically to help to improve follow-up care and treatment. Each individual who requires additional treatment for mental issues is able to see a healthcare provider trained in mental health issues.

National Intrepid Center of Excellence The National Intrepid Center of Excellence (NICoE) is scheduled to open in 2010. NICoE a component center of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, will conduct research, diagnosis, and treatment planning to help the military with psychological health problems and traumatic brain injury.

Other Military Mental Health Assistance The DOD Defense Health Board has the responsibility for the DOD Task Force on Mental Health to assess and made recommendations on improving mental health services. The Board advises the Secretary of Defense for Health Affairs research programs, treatments and prevention of mental illness. Other programs include the Respect-Mil program that uses science based information to identify the treatment by active duty service members at their primary care visit with treatment offered for PTSD and depression. In addition, Military OneSource provides information 24/7 plus referrals to face-to-face coun- 106 Federal Activities in Telemedicine, Telehealth, and Health Technology

seling. Other support centers, health and wellness centers help the soldiers with stress and anger management classes, mental health assessments, and counseling. In 2009, DOD opened a 24/7 outreach center to help service members, veterans, families and others to answer questions about psychological health and TBI. The goal of the Defense Medical Research and Development Program’s Applied Research and Advanced Technology Development is to fund awards for the first time in FY 2010 to advance the state of medical science in the areas of psychological health and traumatic brain injury.

Regenerative Medicine Center for Neuroscience and Regenerative Medicine The Center at USUHS is studying the treatment for TBI and PTSD. The research efforts will be done in six primary areas. To include neuroregenerative medicine to restore neurological function, neuro- imaging, neuroplasticity, rehabilitation medicine, neuroprotection and modeling TBI, and biomarker tools for TBI diagnosis and treatment. A network is being formed in the National Capital Area with WRAMC, NIH, Defense Center for Traumatic Brain Injury and Psychological Health, the Army Medical Research Command Labs, and Navy Labs to accomplish research efforts.

Armed Forces Institute of Regenerative Medicine The military is now applying regenerative medicine to battlefield injuries. Two academic groups from the Wake Forest Institute for Regenerative Medicine and the McGowan Institute for Regenerative Medicine have formed the Armed Forces Institute of Regenerative Medicine and are studying burn repair, wound healing, craniofacial reconstruction, limb reconstruction, and compartment syndrome.

Other Areas of Interest • DOD has developed compression systems with applications to telemedicine, developed a wireless personal information carrier, and developed a miniaturized optical sensor • DOD signed a MOA with the State of Florida to establish a partnership to pursue the cross network exchange of healthcare information • DOD has an imaging system to be used in group settings for photo screening of diabetic retinopathy. The system integrates medical histories, images, and other data. The system has a laptop that acts as a server with a SQL database. • DOD connects doctors treating terminally ill children in Eastern Europe and Central Asia using video conferencing with U.S. specialists. • DOD operates the Centralized Credentials Quality Assurance System to support the management of the professional credentials for active and reserve component health personnel across all services • DOD is involved in adverse-event reporting. The National Practitioners Databank has data on events that resulted in loss of life or limb with the data going to JCAHO. In addition, DOD is implementing a reporting system for less serious mistakes as well as one for near misses modeled after the Air Force practice of studying close calls in aviation. Patient safety activities are being coordinated across the Armed Forces of Pathology, the Uniformed Services University of the Health Sciences, and TRICARE 107 Federal Activities in Telemedicine, Telehealth, and Health Technology

• The Pharmacy Data Transaction Service links patient prescription drug information across several different dispensing programs. With each new prescription, the system scans the patient’s current portfolio of medications for potential negative interactions among the drugs. The system tracks information across several pharmaceutical sources, and determines whether a patient has had a prescription filled at a military treatment facility pharmacy, or at a network retail pharmacy, or through the National Mail Order Pharmacy. DOD is collaborating with VA on the VA Consolidated Mail Order Pharmacy System, and DOD’s direct care pharmacy system. • DOD is looking at the fusion of medical data and health threat intelligence • DOD has adopted the VA’s medical imaging system as the standard and uses the system in worldwide hospitals and clinics

New Developments in Combat Casualty Care • Deployment of an ultra portable system completely inflatable that provides high bandwidth for secure and non-secure data, voice and video. The system can be packed into two carrying cases weighing less than 70 pounds each • Development of vacuum assisted wound closure devices, advanced clotting sponges, and advanced prosthetics • Advances in imaging on the battlefield to provide information on both hard and soft tissue with limited radiation exposure • Surgeons are now able to remove large brain plates, do 3-D imaging, and obtain a description of what has been lost • Devices have been developed that are lightweight, small, mobile, and rugged to be used in the battlefield • CT scanners and handheld blood analyzers are helping to get the wounded to the operating room with the right information at the right time • There are continued refinements in using MRIs in terms of image quality. There are going to be software improvements to allow for varied usage of the modalities and to enable faster imaging • X-rays will be transformed in 5-10 years to produce faster and more accurate diagnostic exams • Landstuhl Regional Medical Center in Germany is using a faster, more accurate, and highly maneuverable voice recognition system. The system being used is the Dragon Medical speech recognition software

DOD Patient Safety Program http://dodpatientsafety.usuhs.mil The Patient Safety Program oversees the DOD Center for Education and Research in Patient Safety, the DOD Patient Safety Center, and the Healthcare Team Coordination Program. DOD has a patient safety web site with one-stop shopping for information of interest to military and civilian patient safety administrators and healthcare providers. The site offers pamphlets on training resources, educational materials plus information is given on DOD’s medical team training program referred to as Team STEPPS. 108 Federal Activities in Telemedicine, Telehealth, and Health Technology

The DOD Medical Patient Safety System (DMPSS) includes the development phase, implementation phase, and the maturation phase:

• The development phase distributed automated tools in the form of a Medication Error Reporting System (MEDmarx), plus an analysis tool referred to as TAPROOT that requires mandatory monthly reporting of medical errors and near misses to the Patient Safety Center • The implementation phase tested the enterprise-wide patient safety reporting system, established electronic safety alerts, and focused on healthcare team coordination training. A Bar Code Point-of-Care Integrated Product Team was formed to outline requirements for a seamless bar code system that ranges from outpatient dispensing of medications to bedside inpatient medication administration • In the maturation phase, the Center will analyze data and look for trends in medical errors and near misses

TRICARE http://www.tricare.mil TRICARE provides care to 9.7 million beneficiaries. To support TRICARE, the Information Man- agement and Information Technology program oversees the development, implementation, clinical administrative, and management for information technology systems. Program Management Offices have several programs:

• Clinical Information Technology Program acts as an acquisition office for centrally managed MHS clinical information technology systems to support the delivery of health services • Defense Medical Logistics Standard Support Program manages facilities, technology, equipment, supplies, and services in the MHS • Executive Information Decision Support Program provides consistent management information to decision makers at military treatment facilities • Resources Information Technology Program provides integrated support to all resource functions within MHS • Theater Medical Information Program provides integrated automation to the theater medical environment • Tri Service Infrastructure Management Program manages the centralized customer help desk along with communications infrastructure activities

TRICARE Online and (www.tricare.osd.mil) has been combined into one site with all the information on that site explaining benefits to DOD beneficiaries. The site provides the Micromedex Consumer Drug Catalog with an online drug interaction checker. The system is able to create individual secure health journals, has access to 18 million pages of information, and can make appointments with primary care providers in a secure manner. Future capabilities will include access to AHLTA, drug renewal requests, routine tests requests, web-based HEAR surveys, and provider-patient secure email. Seven dollars per appointment in administrative and staffing costs are saved when patients make appointments online. 109 Federal Activities in Telemedicine, Telehealth, and Health Technology

TRICARE has a Pharmacy Formulary Search Tool so that beneficiaries can find medication-specific information using either a drug name or medical condition. The tool can be used to check the availability of specific medications, find the medications on the Basic Core Formulary, find co-payment information for prescription medications, learn about generic equivalents for brand-name medications, view prior authorization criteria and forms, and learn about FDA approved drug uses and side effects.

TRICARE Smart Web Site http://www.tricare.osd.mil/tricaresmart TRICARE Smart web site is an improved site to provide faster and easier access to the collection of up-to-date TRICARE marketing and educational materials available on the TRICARE web site.

DOD Joint Efforts Initially the VA and DOD developed a Joint Electronic Health Records Interoperability (JEHRI) plan to enable both agencies to share information, adopt common standards, seek joint procurements, explore the convergence of VA and DOD health IT applications, and develop interoperable health records and data repositories. The DOD/VA Interagency Program Office is working to achieve full interoperability of electronic health record capabilities. DOD and the VA established the Joint VA/DOD Federal Recovery Coordinator Program (FRCP) to integrate care and services for the seriously wounded, ill service members, and veterans. FRCP provides rehabilitation and community reintegration. The program coordinates clinical and non-clinical care management for severely injured service members and veterans across the lifetime continuum of care. DOD and VA have a joint program to train Federal Recovery Coordinators to support medical and non-medical case managers DOD launched the “National Resource Directory” to provide information on care coordinators, providers and support partners with resources for the wounded, ill, and injured service members, veterans, their families, and families of the fallen. The goal is to supply computerized health data so providers in both departments with have the right health information. DOD and the VA are jointly developing an e-benefits web site to serve as a single, customizable, inclusive source for the wounded, ill, and injured service members, and veterans. Complete information in one place will be provided on benefits. DOD and the Department of State are collaborating to determine if DOD’s AHLTA electronic system is a feasible system for the State Department to adopt as its future electronic health record system. If the partnership is established, the State department will use the system to support State beneficiaries overseas. The Federal Health Information Exchange (FHIE) is operational at all VA medical centers. FHIE provides one way transmission of electronic military health data from DOD to VA’s VistA. DOD has transmitted data to the FHIE repository on approximately 3.8 million patients. VA clinicians can view DOD’s Pre and Post Deployment Health Assessment Data (PPDHA). The system has information on separated service members, information on present patients, deployment locations, immunizations, hazardous exposures, and the system provides physical and mental health assessments. The Bidirectional Health Information Exchange (BHIE) provides real-time bidirectional exchange 110 Federal Activities in Telemedicine, Telehealth, and Health Technology of current medical information and displays patient identification management, outpatient pharmacy information, anatomic pathology and surgical reports, cytology results, microbiology results, chemistry and hematology laboratory results, laboratory order information, radiology text reports and food and drug allergy data, and microbiology results. The system is now operational at all VA and DOD sites. Some of the medical facilities now using the system include the Landstuhl Regional Medical Center in Germany, Naval Medical Center, San Diego, Madigan Army Medical Center, William Beaumont Army Medical Center, Eisenhower Army Medical Center, Naval Medical Center, Nellis AFB, National Capital Region facilities, WRAMC, NNMC, Malcolm Grow Hospital, Fort Bragg, and Fort Hood. There are programs enabling the VA and DOD to exchange digital images at El Paso, Texas, Puget Sound area, Hawaii and San Antonio Texas. The VA is able to electronically transfer DOD medical digital images and electronically scan inpatients health records to the VA. This is being done between the Walter Reed Army Medical Center and three of the four Level 1 VA Polytrauma Centers in Tampa, Richmond, and Palo Alto, California, and Minneapolis. The VA is adding this capability from Bethesda National Naval Medical Center and Brooke Army Medical Center to the VA Polytrauma Centers. The Clinical Data Repository (CDR) and the Health Data Repository (HDR) allow for clinical information exchange from DOD and VA medical records. This enables clinicians from both departments to access clinical information from the two repositories. Using CDR and HDR allows DOD and VA to exchange outpatient pharmacy and medication allergy data on shared patients, and check on drug interactions and allergies. The outpatient pharmacy data being exchanged used the DOD Pharmacy Data Trans- action Service. The data includes data from military treatment facility pharmacies, retail pharmacies, and mail order pharmacies. DOD has a CRADA with Microsoft Corp to develop a prototype medical data warehouse and the analytical tools required to allow easy access to military patient health data and records stored in the AHLTA Clinical Data Repository. DOD conducted joint demonstrations with the Department of Veterans Affairs medical facilities to work in three areas that include budget and financial management, staffing and assignment, and medical information technology systems. Medical information and IT systems demonstrations were conducted at:

• California’s Naval Medical Center San Diego and Kirtland Air Force Base in Albuquerque New Mexico interact with the mail order pharmacy system at Leavenworth VA Medical Center in Kansas. • Tripler Army Medical Center and the Honolulu VA Medical Center electronically transmit prescription orders to be filled at Tripler’s pharmacy • The William Beaumont Army Medical Center in El Paso Texas and the adjacent El Paso VA Health Care System formed a joint venture enabling VA patients to receive emergency and inpatient services at Beaumont with backup access to VA surgical suites and computerized tomography services

Other Joint Efforts • The Disability Evaluation System pilot test was designed to eliminate the confusing elements of the two current disability processes of both departments 111 Federal Activities in Telemedicine, Telehealth, and Health Technology

• DOD provides access to the web-based Joint Patient Tracking Application (JPTA) to VA providers. A modified application of JPTA, known as the Veterans Tracking Application (VTA) collects, manages, and reports on patients arriving at military facilities from forward deployed locations. VTA is compatible with JPTA with information coming directly from the battlefield to help the VA coordinate transitioning soldiers. The application tracks benefit claims, and provides electronic access to clinical information from the point of injury in the theater • DOD provides the names of individuals who enter the Physical Evaluation Board to determine if they are fit to stay on active duty or should they be medically separated to the VA • DOD and the VA have established 504 sharing agreements covering 2,090 health services • A VA/DOD Mental Health Working Group has been formed to find ways to support mental health needs • DOD military treatment facilities and reserve units are involved in sharing agreements with 157 VA medical centers • VA is partnering with DOD medical facilities through a Cooperative Separation Physical Examination and Benefits Delivery at Discharge program • DOD and VA are working together to develop the joint Evidenced-based Clinical Practice Guidelines • DOD/VA’s behavioral healthcare providers are integrated into primary care clinics • DOD and the VA have increased joint procurements and are jointly publishing used evidence-based clinical practice guidelines for disease management • The Interagency Virtual Private Network provides for the exchange of clinical data between DOD, VA, and the Laboratory Data Sharing and Interoperability Project (LDSI). DOD is able to act as a reference laboratory for chemistry tests performed for the VA. The LDSI application supports the bi-directional exchange of orders resulting between agencies so that each agency can serve as a reference lab. For example, In Hawaii, the Spark M. Matsunaga Medical Center uses the laboratory module of VistA to electronically route requests to the Laboratory at Tripler Army Medical Center. Upon completion of the ordered tests, Tripler electronically routes the laboratory test results back to VistA. DOD is currently planning implementation of the initiative at Wilford Hall Medical Center, Brooke Army Medical Center, and the South Texas Veterans Health Care System • The VA is partnering with Naval Medicine allowing military medical leaders access to a VA database of healthcare on “lessons learned”. The VA database information is available to military health care providers via their desktops, and contains a range of topics, including quality improvement plans, ways to improve patient satisfaction, and how to make more efficient use of health care funding • DOD/VA Health Executive Council is working with industry to synchronize data on items from manufacturers and items from prime vendor distributors • DOD and VA have collaborated on projects related to occupational and environmental exposures. • The DOD/VA Consolidated Mail-Out Pharmacy (CMOP) interface helps the VA fill an average of 8,000 orders and 10,000 prescriptions per week. Military beneficiaries treated at Naval Base Coronado, Naval Air Station, San Diego, and Kirtland Air force Base, 112 Federal Activities in Telemedicine, Telehealth, and Health Technology

Albuquerque New Mexico can choose to have their outpatient prescriptions filled by the CMOP at Fort Leavenworth, Kansas and mailed to them • Active-duty sailors and veterans in Chicago go to one health care facility at the North Chi- cago Veterans Affairs Hospital. The facility houses a $110 million ambulatory care center and share electronic health records • The VA and TRICARE Management Activity are spending $2.5 million to redesign their beneficiary health web portals and comply with standards • VA and DOD are working together on developing budget and financial systems to improve changes needed for billing and other projects

University Collaborations The Defense Department has a strong collaborative relationship with universities, and invests more than $1 billion per year in research and research-related activities in the academic community. There are several university programs:

• DOD awarded funding to the Bascom Palmer Eye Institute and two other Centers of Excellence from the University of Miami, Miller School of Medicine to support research on traumatic eye injury and visual restoration, hereditary eye disease, and ophthalmic imaging, and telemedicine • The Center for Commercialization of Advanced Technology (http://www.ccatsandiego. org) funded by DOD is a public private collaborative partnership between academia, industry, and government. Partners include San Diego State University, University of California, (San Diego), Lockheed Martin ORINCON Technologies, and the Space and Naval Warfare Systems Center • DOD awards grants to academic institutions to conduct multidisciplinary research in 26 topic areas of basic science and engineering. These grants are made under the DOD Multi- disciplinary University Research Initiative program. • In 2009, DOD, awarded 28 grants totaling $1.4 million as part of the Defense Experi- mental Program to Stimulate Competitive Research to enhance research and engineering capabilities at 20 academic institutions • DOD awards contracts to academic institutions to purchase research instrumentation, under the Defense University Research Instrumentation Program (DURIP). The program purchases of state-of-the-art equipment to augment current university capabilities to perform cutting edge defense research. DOD solicits proposals from university investigators involved in information technology, remote sensing, propulsion, electronics and electro- optics, advanced materials, and ocean science and engineering. • DOD awards academic institutions research grants to conduct nanotechnology research in 15 topic areas of basic science and engineering, under the DOD Defense University Research Initiative on Nanotechnology program (DURINT) • The University Affiliated Research Center is developing nanometer scale science and technology solutions for the soldier, and develops materials to use for an advanced uniform concept to incorporate cyberspace and technology • DOD’s Peer Reviewed Medical Research Program (http://cdmrp.army.mil) has spent $300 million since 2005 to fund nearly 200 projects on a range of medical topics. Funding 113 Federal Activities in Telemedicine, Telehealth, and Health Technology

helped the University of Massachusetts Medical School develop a sensor device to alert caregivers of impending problems • DOD provides funding to the Center for Bioelectronics, Biosensors, and Biochips (http:// www.clemson.edu/c3b/) at Clemson University to develop an implantable biochip to relay vital health information if a soldier is wounded or a civilian is hurt in an accident

Programs to Study Military Healthcare Task Force Studying the Future of Military Healthcare http://www.dodfuturehealthcare.net The Task Force appointed by the Secretary of Defense discussed developing wellness initiatives and disease management programs, tracking health risks, education programs focusing on patient initiated healthcare, accurate costs of healthcare in the military system, and how to improve existing procurement activities. The final report has been released with a number of specific recommendations for sustaining military healthcare services.

DOD Blast Injury Research Program The program is fitting helmets with blast sensors to be used in combat to gather data. The data will be recorded along with other operational data and entered into an intelligence database with the National Ground Intelligence Center. After the data is studied, then the data will be matched with injury data. The data will be available through the joint Trauma Analysis and Prevention of Injury in Combat Program.

Healthcare Quality Initiatives Review Panel The Healthcare Quality Initiatives Review Panel is studying how DOD can improve the quality of healthcare and how to provide better education and training programs to physicians and other health care providers. This advisory committee is working to establish “Centers of Excellence” for complicated surgical procedures.

Deployment Technologies and Support Program DT&SP provides oversight for theater health-related technology programs to ensure that DOD maximizes the use of technology and information systems to improve performance. DT&SP provides oversight to ensure that electronic healthcare information systems and technologies developed for use in the theater/contingency operations meet functional business practice needs and validate user requirements.

Force Health Protection and Readiness Program DT&SP supports the Force Health Protection and Readiness Program. The Force Health Program is involved in deployment medical polices and activities and evaluates data on health conditions in the military. The program created the “Embedded Metal Fragment Registry” to enable veterans that have had unrecoverable fragments removed send this information to a database. This information will help the military to know what the enemy is shooting at our military and what type of enemy roadside devices are being used. This information will be included in any service member’s electronic record. 114 Federal Activities in Telemedicine, Telehealth, and Health Technology

Addressing Disabilities Computer Electronic Accommodations Program CAP is a centrally funded assistive technology program that buys and delivers hardware, software, and services to people with disabilities so that they can function in the workplace. The technology makes the electronic environment accessible to and usable by individuals with hearing, visual, dexterity, cognitive, and communications disabilities.

Armed Forces Medical Intelligence Center http://www.afmic.detrick.army.mil The AFMIC a part of the Defense Intelligence Agency is the sole DOD producer of medical intelligence. The Center provides intelligence on foreign infectious diseases and environmental health risks that might affect military and civilian healthcare systems. Assessments, forecasts, and databases are prepared on foreign, military and civilian healthcare capabilities and trends, worldwide infectious disease occur- rences, global environmental health, and significant life science issues to include biotechnology, nuclear, biological, and chemical medical defense advancements. A key project is using cutting-edge modeling and simulation techniques to enhance foreign health care system assessments to compare medical capabilities.

Deployment Activities There are several programs to help study deployment activities. The DOD Deployment Health Clinical Center provides for deployment-related healthcare across the MHS. The Office of Force Health Protection and Readiness Policy and Programs have developed the DeployMed ResearchLINK. The site (http://deploymentlink.osd.mil) provides information on government-funded scientific studies of medical issues experienced by military members during deployments. The DOD Center for Deployment Health Research along with the Naval Health Research Centers serves as the medical research laboratory looking at issues involving deployment in the military.

DOD SBIR Periodically, DOD releases SBIR solicitations with topics from the Air Force, Army, Navy, DARPA, CBD, OSD, and DTRA. Basically, the program is looking for research to provide automated reality systems to use for training healthcare providers, to develop advances in immersive reality technologies with those of mannequins or actor-based systems, and to develop hand-held devices to analyze proteins in the blood and to detect viruses in the blood at the point-of-care. The Office of the Secretary of Defense is interested in SBIR research in health surveillance planning and decision support tools, new methods to monitor health status and clinical laboratory data, medical training and learning tools, and medical simulation-based training systems. The Biomedical Technology Defense Health Program is specifically emphasizing research to help individuals with traumatic brain injuries. For example, the Army seeks to develop PC or web-based video game applications to improve cognitive, motor, and sensory performance, a portable system to use on the battlefield triage to monitor traumatic brain injuries, a virtual reality based assessment tool to determine return-to-duty status of patients, and a computing interface to be used for cognitive and physical rehabilitation. 115 Federal Activities in Telemedicine, Telehealth, and Health Technology

Institute for Defense and Homeland Security http://www.idhs.org The Institute is operated by the Center for Innovative Technology, a state-charted non-profit corporation to accelerate next generation technology and technology companies. Emphasis is on telecommunications, biodefense, sensor systems, risk management, crisis management, and remote systems. Members of the Institute come from universities, industry, and from federal research and development organizations.

Defense Technical Information Center http://www.dtic.mil/dtic DTIC provides the military, researchers, scientists, engineers, laboratories and universities timely access to over two million publications covering over 250 subject areas. DTIC is a DOD field activity within the Under Secretary of Defense for Acquisition, Technology and Logistics reporting to the Direc- tor, Defense Research & Engineering.

Federal Procurement Data System http://www.fpds.gov DOD is now fully integrated in real-time with FPDS-next generation providing both the public and private sector visibility into a significant portion of federal spending and is able to deliver service to more than 100,000 registered users of the system. DOD is the largest provider of data to the system and has over 35,000 users. FPDS-NG was created to provide greater transparency into government contracting, provide a powerful business decision-making tool for the contracting community, create a foundation for standardizing contracting processes, and provide for a self-service web accessible reporting tool.

Defense Solutions http://defensesolutions.gov Companies, entrepreneurs, and research organizations can now start targeting ideas on potential solutions, new products, services prototypes, and concepts to DOD by approaching the defense solutions program.

Army Telemedicine Activities TATRC http://www.tatrc.org The U.S. Army Medical Research and Materiel Command (USAMRMC) has responsibilities for medical research, product development, technology assessment, health facility planning, and medical information management and technology. The MRMC works with laboratories, development centers, and the Engineering Command. In the medical logistics area, MRMC has developed an effective partnership with the Defense Logistics Agency to increase the medical purchasing power of the Defense Working 116 Federal Activities in Telemedicine, Telehealth, and Health Technology

Capital Fund. The command also coordinates activities with the Department of Homeland Security, HHS, USDA, and other non DOD federal agencies. Collaborative efforts are underway to build the National Inter- agency Biodefense Campus at Fort Detrick. The U.S. Army telemedicine R&D program is administered by the Telemedicine and Advanced Technology Research Center (TATRC) at Fort Detrick Maryland, and currently manages over $300 to $400 million in research and development projects in telemedicine and advanced medical technologies. Most of the work is carried out through partnerships with other research organizations, government, and universities with TATRC providing leadership. Telehealth applications have been deployed in dermatology, ophthalmology, infectious diseases, cardiology, pediatrics, nephrology, burn and trauma, toxicology, dental, pathology, and post surgical management. More than 70 teleradiology systems and 22 telepathology systems are linked, plus teleo- phthalmology and teledermatology systems are in place. The goal is to develop technologies to save lives and treat serious injuries on the battlefield by reducing the time lag in providing critical care, and improve the quality of the care. The primary challenge is to provide biologics, pharmaceuticals, and devices to help first responders treat casualties. The Combat Casualty Care Research Program within USAMRMC researches advanced noninvasive physiologic sensors and technologies to improve the acquisition and availability of blood products. TATRC developed BMIS-T, the Chest Tube Simulator, Digital x-ray, and the Dreams Digital Ambulance. In addition several Army medical centers provide telehealth expertise worldwide:

• Landstuhl Regional Medical Center provides radio support to Europe and Southwest Asia • Brooke Army Medical Center does 500 dermatology a month, and provides consultations in cardiology • Tripler Army Medical Center provides 30 pediatrics consultations a month, and the eICU consults with Guam Naval • Walter Reed Army Medical Center provides psychiatry and neurosurgery consultations

The Army is currently establishing a Collaborative Technology Alliance in the area of Robotics. The Army wants the alliance to bring together government, industrial, and academic institutions to address some of the fundamental scientific and technological activities on the future deployments of highly autonomous unmanned systems. The technical areas include perception, intelligence, human-robot interaction, dexterous manipulation and unique mobility, and integrated performance. Contingent upon funding, the Robotics Alliance is expected to be supported for five years with an option for an additional five years at eleven million per year.

TATRC Organization Clinical Applications Division integrates advanced technology with clinical business practices, looks at technology in the federal sector and industry to find advanced medical technologies, tests technologies used, develops databases, and developing simulators to improve the educational information for students Advanced Information Technology Group works on medical devices to transmit patient information and is implementing wireless information access 117 Federal Activities in Telemedicine, Telehealth, and Health Technology

Mobile Computing Division studies mobile computing solutions to use to train others to obtain and use medical data on health issues and surveillance Program Integration and Planning Division manages congressionally mandated programs dealing with disaster relief and emergency medical services

Collaborative Efforts TATRC uses the Triple Helix Approach to bridge the gaps between the R&D process and getting the developed technology to the soldier. TATRC forms partnerships with academia, government, and industry to speed up technology transfer from universities to the private marketplace. TATRC also works with professional societies, associations, and centers, to help develop advanced medical technologies to reach the marketplace at a rapid rate. Integrated Research Teams listen to non-medical experts on pairing biomedical and grid expertise to develop collaborative partnerships to concentrate on life sciences with a focus on computation. Team participants learn about current biomedical research and discuss the strategic partnerships that have already developed.

Funding Options TATRC funding options are:

• Congressional Special Interest (CSI) projects are congressionally directed and do funded research. The projects generally address issues of national importance with funding of about $1 million for periods of two years but must be approved through the appropriation process • Unsolicited proposals range from basic research to technology insertion, and funds are about $200,000 for periods of one year. • Broad Agency Announcements are a mechanism for submission of CSI projects and unsolicited proposals. Pre-proposals are submitted online followed by a full proposal if requested • TATRC Discretionary Funding addresses issues of relevance to TATRC’s mission and portfolio with range of projects from basic research to technology insertion. Funding can be $200,000 for periods of one year because long term projects aren’t funded. • SBIR program provides up to $850,000 in early stage R&D funding directly to small technology companies for individual entrepreneurs who form a company. The STTR program provides up to $600,000 in early stage R&D funding directly to small companies working cooperatively with researchers at universities and other research institutions. • Demonstration projects such as the Army Medical Department Advanced Medical Tech- nology Initiative fosters collaboration between industry, academia, and AMEDD to validate advanced medical technologies and to foster medical technology entrepreneurship. Another project the Advances in Medical Practices program is open to AMEDD personal and identifies advanced medical devices, treatments, and systems to improve the cost and access to quality care. 118 Federal Activities in Telemedicine, Telehealth, and Health Technology

Initiatives Advanced Medical Technology Initiative The Advanced Medical Technology Initiative (AAMTI) provides the AMEDD leadership with medical technology watch capabilities and encourages entrepreneurship by funding AMEDD technology innovators. AAMTI is a $5 million demonstration program with 20-24 awards per year that have an impact on costs, access, and the quality of care. The program also demonstrates CSI, SBIR/STTR and COTS technology, and funds optimal retinal cameras, simulators, surgical robots, a mental health intake system, multi-site phonocardiography, and wireless wearable ultrasound scanners.

Global Telemedicine Initiative TATRC is looking for opportunities to develop partnerships with health organizations, universities, non-profits, NGOs, governments, and the World Health Organization. TATRC held a joint meeting with the American Telemedicine Association to have dialogue and discuss various initiatives on how to use telemedicine to provide better healthcare services to people in need worldwide. As a result of the meeting, a report was published and an article appeared in the publication “Telemedicine and e-Health”.

Bioanalysis Institutes http://www.bhsai.org The Biotechnology High Performance Computing Software Application Institute develops HPC software applications to support the DOD biotechnology community including research for the Army, the Navy, and the Air Force. BHSAI is co-located with the AMRMC’s Bioinformatics Cell at Fort Detrick, Maryland.

Robotics and Artificial Intelligence The Maritime Forces of 2030 program looks for affordable projects to make use of unmanned autonomous vehicles, provide advance life support systems such as the Army’s LSTAT, improve care while enroute, use robotics enhanced surgery, send 3-D holographic presentations of patients including virtual imaging of internal injuries and structures, use diagnostic micro-devices to be ingested or injected into the body to report in-vivo on the condition of the gastrointestinal tract and circulatory system, and a way to inject nanomachines that would go to an injury site and perform micro repairs at the cellular level.

Wireless Medical Enterprise Working Group http://www.tatrc.org/website_wme/home.html The TATRC Wireless Medical Enterprise Working Group provides intra-office and inter-office coordination for research and development efforts. The web site serves as a portal to the activities of the working group. 119 Federal Activities in Telemedicine, Telehealth, and Health Technology

TATRC and Collaborative Research Programs Health Information Technologies The Advanced Information Technology Group is focused on establishing an AHLTA common development environment, establishing a research data cube/clinical data mart to develop a de-identified longitudinal MHS data set, and establish an IM/IT platform (OASIS) to develop emerging technologies. Other IM/IT projects include Natural Language Processing, voice recognition, scanning paper-based medical records, interoperability, usability testing of EHRs, and terminology services, development of the Clinical Looking Glass, interfacing with NHIN, and speech recognition and language processing

Medical Imaging Technologies The Advanced Medical Imaging Portfolio includes projects on portable imaging and image guided therapeutics, high performance imaging, computational methods and decision support in imaging, and optical and para-optical imaging techniques. TATRC is working on forging new pathways into laser and optical imaging as well as the science of multimodality image fusion. Researchers are developing new optical tools such as the advanced surgical camera, high performance brain imaging to be internet accessible to support distributed telemedicine applications, improving computer aided cancer management, development of portable imaging for the detection of breast cancer in young women, development of an ultrasound probe to provide high resolution images, and the development of sonography to use in cases of trauma. Research is ongoing to combine advanced technologies in other research fields. Combining Proton Beam Radiation Therapy with Advanced Robotic Guidance and fusing optical technologies with neuroprothetics are examples.

Medical Robots The Robots portfolio is collaborating on:

• Working with the Tank Automotive Research Development Engineering Center and the Robotics Systems Joint Program Office on robotic casualty extraction and evacuation. • The Joint Medical Distance Support and Evacuation Joint Concept Technology Demon- stration project will provide for virtual triage from secure areas with a battlefield telemedicine and closed loop critical care capability • A series of telesurgery experiments with NASA and McGill University, plus DOD and NASA on doing experiments in extreme environments • Operating instruments connected to robotic systems with multiple surgeons using the instruments in different locations • Studying ongoing delays in transmission and the interruptions of the electronic signal, and working to make robots smaller and more portable • Developing the trauma pod program with DARPA to provide teleoperated or even autonomous care and lifesaving surgery on the battlefield and during evacuation • Robotic research strategies include integrating robots with HIFU to use on board support systems such as LSTAT. LSTAT incorporates many of the functions of an ICU, but is contained entirely within a stretcher 120 Federal Activities in Telemedicine, Telehealth, and Health Technology

• Being able to better detect chemical and biological agents and IEDs • Developing robots that will be able to drive vehicles to provide supplies and recover contaminated combat casualties and KIAs • Developing better sensors, human physiological models of soldiers, and more advanced imaging • Developing an advanced robotic evacuation system to use with UAV platforms, further development of BEAR, integration of seamless soldier robotic control devices, and integration of UWB and JAUS • Developing the Operating Room of the Future to improve patient safety, by using advanced devices to do telesurgery, and using robotic devices, communication tools, and smart tools for minimally invasive surgery. CIMIT and MGH are collaborating on the ORF program with other industry partners • Development of sensors on a casualty extraction robot to assess the degree of the soldier’s injury

Computational Biology The MRMC’s Bioinformatics Cell and Biotech High Performance Computing Institute supports studies on bioinformatics/informatics applications that will be capable of analyzing huge quantities of gene and protein data to gain insight into therapy, drug targeting, and the diagnosis of biological threats. The program works on data validation, warehousing, data mining, and predictive algorithm development. Researchers are studying next generation biomathematical models to allow for individual specific real time 20 minute ahead predictions for core temperature and glucose readings. TATRC is working on making more accurate predictions using a model that can be portable from individual to individual, predicting core temperatures in advance to prevent health injures, addressing how to predict the status of casualties during evacuation, predicting the effects of fatigue and sleep deprivation, developing software systems to support diagnostic assays to identify drug and vaccine candidates, developing protein-protein interactive networks, and metabolic networks

Advanced Prosthetics and Human Performance The portfolio is aimed at providing advance prosthetics, assistive devices, treatments and interventions for patients with major limb amputations. Current projects include Powered and Regenerative Kinetics Prostheses, Advanced Socket Design, and Dynamic Sensing Socket, Osseo Integration Infec- tion Prevention, Limb Trauma Outcomes, Gait Training System, and Orthotic and Prosthetic education. The portfolio provides funding and oversight to the WRAMC Military Amputee Training Center and the Center at Brooke Army Medical Center. TATRC is cooperating with DARPA’s prosthetics program and the VA on related research efforts, plus providing funding and management on congressionally sponsored projects as well as management oversight for SBIR and STTR. A grant was awarded to WPI’s Bioengineering Institute to advance the development of neuroprosthetics—next generation artificial limbs. Researchers are working to successfully transplant human hands 121 Federal Activities in Telemedicine, Telehealth, and Health Technology

Regenerative Medicine The portfolio looks at advancements in tissue engineering and stem cell technologies to create replacement tissues, organs, and limbs, and develop novel cell based therapeutics to improve wound healing, foster cell proliferation in vitro, and produce tissue generation in three dimensions. Studies are ongoing on the human ear project with CIMIT, studying how to make new blood vessels from human cells, how to develop rapid fracture healing using gene therapy, and how to develop rapid assays to detect anthrax.

NanoMedicine and Biomaterials TATRC oversees projects ranging from developing new nanomaterial-based contrast agents for cardiac, developing physiological sensors to diagnose and to permanently implant the devices, research on brain imaging, and ways to provide better drug delivery systems for the treatment of cancer. Researchers are studying how to develop implantable biosensors that can function effectively within the body. TATRC is collaborating with Northwestern University Institute for Bioengineering and Nanoscience in Advanced Medicine to study how nanosensors can detect and report casualty information, how to develop minimally invasive field surgical instruments, how to develop implants to dispense drugs in response to body changes after a wound, and how to develop nanostructures to stop bleeding in the field. TATRC has formed an alliance for nano-health at Rice University, to work with the University of Texas Health Sciences Center at Houston, the University of Texas MD Anderson Cancer Center, University of Hous- ton, and Baylor College of Medicine. The biomaterials portfolio works on tissue engineering, drug delivery, and developing physiological sensors to diagnose, and developing permanently implanted devices such as sensory, cardiovascular, orthopedic, and dental devices.

Chronic Disease Management Areas of interest include tele-robotics and simulation, refractive surgery, modulating ocular response to injury and disease, ocular and visual restoration, and novel projects. Plans are to look at trauma, infection and inflammation, retinal and corneal diseases, glaucoma and optic neuropathies, strabismus, amblyopic, and visual processing, along with low vision and blindness rehabilitation. The program is collaborating with the Joslin Diabetes Center on a comprehensive diabetes management program with the Children’s Hospital of Pittsburgh to study genetic inheritance patterns, biomarkers. They are also developing educational programs, with the Marshall Island Diabetes Wellness and Reversal Program to study lifestyle changes and diets to help reduce type 2 diabetes. Plans include doing endocrine pancreatic re- generation and working on a non-invasive glucometer. Investment areas include home telehealth care and embedding clinical practice guidelines into the EHR. The goal is to develop home monitoring and informatics via multi-media longitudinal electronic patient records with PHRs. The portfolio supports ocular health projects with the Schepens Eye Research Institute and the Wills Eye Hospital. The Schepens Eye Research Institute studies eye conditions resulting from battlefield conditions in terms of degraded vision, low vision, and laser damage. Wills Eye Hospital is screening large populations for diabetes, and using glaucoma screening to identify pre-existing ophthalmologic diseases. 122 Federal Activities in Telemedicine, Telehealth, and Health Technology

Infectious Disease The goal is to protect the health of the military by advancing technology to prevent, detect and provide the most effective treatments for infections and parasitic diseases and develop new tools to combat evolving drug resistance. Researchers are studying models of human lung tissue to find out how tissue cells interact with infectious agents. Studying immune-stimulating therapies for HIV and other immuno- deficiency diseases,

Bio Sensors/Bio-Surveillance TATRC is developing links with autonomous data sources to detect potential bioterrorism attacks from medical data, pharmaceutical sales, and other information coming from satellites. TATRC is applying biosurveillance technology to Unmanned Aerial Vehicles, to find new or existing detection methods, and combine these methods to focus on water surveillance within CONUS and OCONUS.

Biomonitoring Technologies This portfolio invests in the development and integration of systems and/or platforms of mobile technologies that enables wireless and/or remote monitoring of a person’s health and/or environment including but not limited to physiological status from the battlefield to the hospital to the home. The next step is to integrate these technologies and develop decision support tools to improve medical treatments and improve the first response to a critical situation.

Simulation and Training Technology Four research categories in this portfolio include PC based interactive multimedia, digitally enhanced mannequins, virtual workbenches, and total immersion virtual reality. Completed MM&S projects include simulation meta-analysis, ENTSurgical simulator, STATCARE, ureteroscopic endoscopic simulator. Future plans are to continue to develop enabling technologies, do training transfer studies, support open source/architecture standards, converge S&TT research with surgical robotics, education, entertainment, virtual reality and apply what is learned to behavioral health, and transition products that are relevant to the military, to the private sector and end user communities.

Neuroscience This portfolio spans cellular, pharmacologic, proteomic, imaging and clinical studies to identify mechanisms to enhance the diagnosis and treatment of neurotrauma and neurodegeneration. The goal is to develop effective diagnostic tools and therapies to enhance military health. Examples include working on brain injury biomarkers and therapy and on a program called the Comprehensive National Neuro- science. TATRC also is working on the first version of a neuropsychological test system to use in mass military situations, studying prevention techniques to use to help soldier’s with Parkinson’s and to prevent Parkinson’s, new treatments for spinal injuries, innovative treatment of TBI

Medical Logistics The military needs to deliver supplies on time and track supplies using technology. Projects include using RFID for tracking supplies, robots to deliver medical supplies, be able to perform remote diagnosis, repair medical equipment, and develop smart medical equipment 123 Federal Activities in Telemedicine, Telehealth, and Health Technology

Proteomics/genomics Proteomics is being used to identify markers for early detection of cancer and to identify new therapeutic targets. These techniques will result in the rational design of personalized cancer therapeutics. Bioinformatics plays a pivotal role in ensuring that these discoveries are statistically valid. Special- ized software and databases are being developed, disseminated, and used to mange de-identified patient information and research data. Large tumor banks have been established to identify, catalogue, and store tumor samples as well as normal tissues, plasma, serum for research protocols Microarray analyses of cells from the tumor banks are being used to develop signatures to allow diagnosis and prognosis.

Some of the other TATRC and Collaborative Projects Traumatic Brain and Eye Injury Initiatives The AMEDD-wide Regional Medical Command’s Tele-TBI Projects will have personal and equipment to effectively provide tele-TBI care. Each region will have telemedicine equipment and support personnel in needed locations. The Tele-TBI Cell Phone Initiative is a project leveraging cell phone data exchanges between patients and providers to help modify behaviors and improve clinical outcomes. The project creates a two way means of communication between the soldier and their families with the platoon sergeants and nurse case managers using a web interface to initiate and manage messages. The AMEDD Transcranial Doppler Program provides for brain ultrasounds to be a safe noninvasive and repeatable procedure to assess and monitor cerebral vasospasm. It is used to prevent patients from suffering further ischemic injury to the brain. Ocular trauma research supports the Defense Center of Excellence for Traumatic Eye Injury. Researchers are developing retinal prosthesis that is designed to restore vision to some blind patients. Other groups working on multiple projects to help prevent injuries to the eye, include Schepens Eye Research Institute, Center for Ophthalmic Innovation, and the Wills Eye Institute.

Video Teleconsulting TATRC is using video teleconsulting along with diagnostic scopes and high-speed file transfer. Since its initial use in Somalia, remote teleconsultation has been used in Macedonia, Croatia, Haiti, and Kuwait. Medical officers in the field communicate with specialty consultants in medical centers, to improve emergency trauma management and provide quicker patient evacuation.

Teledentistry TATRC has developed a web-based communication technology to collect, send, and disseminate data relating to a patient’s condition. The system includes a storage capability enabling the data to be accessed or amended at any time. This teledentistry consult system allows for expert consultations to go to theater-based dentists and soldiers and the system provides for electronic records.

PARRTS TATRC is using the Patient Accounting and Reporting Real-Time Tracking System (PARRTS) in Iraq to deliver information immediately. Clinical data is entered immediately on wounded personnel 124 Federal Activities in Telemedicine, Telehealth, and Health Technology so that medics can respond to commanders in the field who want updates on the status of the wounded soldier.

Other Ongoing and Future Technology Development TATRC is working in several areas:

• TATRC and the University of California (San Diego) and the University of Hawaii are using bioinformatics, grid computing and networking infrastructure as well as collaborating with Asian Institutions to learn about flu. • Evaluating a portable tool for use by first responders in documenting triage of victims in a mass casualty incident more effectively • Researching web-based internet telemedicine management systems to work with heart failure patients • Researching voice technologies for educational purposes to use effectively in treating diabetes • A CSI project funds the Center for Innovative Minimally Invasive Therapy (CIMIT) and works with a consortium of nonprofit institutions to diagnose and treat patients using minimally invasive approaches while treating cardiovascular disease, cancer, stroke, trauma, and critical care. CIMIT’s Enabling Technologies for Medical Simulation Project is developing medical simulation training devices to train combat medical personnel in trauma procedures to respond to wound conditions and medical treatment interventions • TATRC and the National Bioterrorism Civilian Medical Response Center, a congressionally sponsored research program at Drexel University and St. Francis University Center of Excellence for Remote and Medically Underserved areas, are using UAVs for medical surveillance and forward command and control of unmanned ground vehicles. DARPA also has an ongoing project in this field called Nightingale. • TATRC is exploring new applications for internet-based remote medicine. The telemedicine program is caring for soldiers using an image sharing system to help Army pathologists make remote diagnoses in minutes. A hospital in Afghanistan uses the Brigade Remote Subscriber System (BRSS) to link with Landstuhl Regional Medical Center in Germany. These connections allow simultaneous two-way voice, data and high resolution video transmissions. The network includes dermatology, ophthalmology, psychiatry, radiology services, with X-rays, ultrasounds with CAT scans sent to Landstuhl for second opinions • Microvision Inc. and the Army are developing a mobile wireless personal display system for medical applications. The Army’s “Informedic” concept to produce a mobile medical system will enable military surgical personnel and medics to access, read, and transmit critical medical data via a head worn display, wearable computer, and wireless network • IMEDTools are being developed to provide a computer-based medical decision support system to monitor combat casualties and assist medics in the diagnose, triage, stabilization for critically injured combat casualties. • MEDITAGG a Personal Information Carrier Device stores, transports and adapts to a wide range of needs. The military needs to store progress notes of physician laboratory results, and multimedia digital information such as chest x-rays and the sound of heart murmurs. 125 Federal Activities in Telemedicine, Telehealth, and Health Technology

Sometimes, these multimedia-based medical records can be large in size and – difficult to transport the information from the battlefield. Future developments will take the current storage technologies into optical storage technology where light will become the medium of information storage and transmission

Other TATRC and Army-Wide Projects Tracking Blood Supplies The Army is able to track blood supplies in Iraq and Afghanistan using the Socket Cordless hand Scanner. The Army is using a mobile blood management system with a scanner with Bluetooth wireless technology, plus using an HP iPAQ Pocket PC and Blood Information Program software developed by TATRC to deploy blood bank units to the battlefront. The Army has developed a highly portable system to treat hypothermia in the field. The system warms a patient’s blood and then returns it to the patients. In 2009, DOD was able to develop a stable and cost effective means for quickly and accurately determining the blood type of potential donors. The new Micronics ABO/Rh Card is a disposable credit card-sized device that can accurately determine ABO blood type and RH factor from a single drop of blood in less than 30 seconds. It is the first device that does not require refrigeration or supporting equipment and works in a closed system to protect the blood sample and reagents from environmental contaminations.

Warfighter Refractive Eye Surgery Program http://www.tatrc.org/website_RSIS/index.html The Warfighter Refractive Eye Surgery Program (WRESP) tracks the long term benefits of refractive surgery. Collection of surgery data is maintained through the Web-Enabled Refractive Surgery Information System (WebRSIS). The Standard Refractive-Surgery Data Report (SRDR) automatically summarizes the outcome from multiple surgeries. The information shows cumulative totals for all surgeries performed with breakdowns on outcomes and data on follow-up visits.

Voice Recognition System The Army’s Tactical Combat Casualty Care Committee wants to develop an effective voice recognition system that the first responder can use. This is needed since first responder or medic documentation is often missing, inaccurate, unintelligible, or incomplete. The Army seeks to expand existing commercial or government voice and communication technologies to help develop an easy to use device capable of capturing critical clinical information.

Mental Health A task force has studied mental health issues and submitted a report to the Secretary recommending ways to improve mental health care for service members and their families. A behavioral health web site at (www.behavioralhealth.army.mil) provides information on behavioral health needs before, during and after deployments, along with pre and post deployment health assessments, information on PTSD and suicide prevention, battlemind training, and resources where soldiers and families can get help. The Army supports the National Trauma Institute to increase research on trauma and emergency 126 Federal Activities in Telemedicine, Telehealth, and Health Technology

care. The NTI combines the resources of Wilford Hall Medical Center, the University of Texas Health Science Center, Brooke Army Medical Center, the Army Institute of Surgical Research, and the Uni- versity Health System. The Army will study resuscitation, monitoring and metabolic control of injured military and civilians.

Ultrasound Inroads are being made in using ultrasound because very small and portable equipment is needed to use in the field at the point-of-care. Using four dimensional imaging which is actually 3-D plus real time imaging ultrasound technology, is becoming more common. Another ultrasound technology similar to 4-D, called holographic ultrasound, is able to go through soft tissue in the body and make holograms that can see more detailed images.

Training for Dentists The Army Dental Corps established a telemedicine network in Germany and Italy, that uses desk top videoconferencing systems, associated video devices, to train dental personnel at 30 clinics. This allows dentists at remote clinics to use phone lines to video consult with specialists on a variety of dental problems.

Landmines USAMRMC is looking at using telemedicine to rehabilitate victims of landmines, how to provide computer aided training systems for medical staffs, develop and implement telementoring and teleconsultation technologies, and support telecommunications and information technology systems.

Technologies Deployed in the Field Battlefield Medical Information System-Telemedicine BMIST provides first responders and forward-deployed physician’s access to critical information, knowledge, medical consultations, and improves the quality of medical data acquisition, processing, and the storage of information. The Personal Information Carrier used with the system stores medical information and sends the data via BMIST. With BMIST as part of the Theater Medical Information Program, all medical encounters during a deployment can be transmitted to AHLTA, the U.S. Special Operations Command Health Surveillance System, and the Clinical Data Repository. BMIS-T is now integrated with an Electronic Information Carrier, a virtual retina scanning laser image display, automatic speech recognition, reference materials, and physiological sensors. BMIST, Speech Capable PDA Prototype, and NOMAD Infomedic project managers are collaborating to help first responders have hands-free access to medical data and decision support tools simultaneously while performing hands-on care. This capability enables Army medics to voice operate their computers via an advanced microphone system and view screen images via a see-through heads-up virtual retina scanning laser image display system. 127 Federal Activities in Telemedicine, Telehealth, and Health Technology

MC4 Program http://www.mc4.army.mil/index.asp The Medical Service Corp at Ft. Detrick sends notebooks and handhelds to battlefield medics in Iraq as part of the Medical Communications for the Combat Casualty Care program (MC4). The MC4 is a medical tracking system to capture pre and post deployment medical histories and treatments received during deployments. Medics entering information directly into a soldier’s medical records are able to track the symptoms for patients throughout the theater as well as for injured and deceased war fighters. The Army and Air Force have completed the largest training and equipping effort for digital medical recording systems. Now 200 Military Treatment Facilities are using MC4 to electronically document patient care on the battlefield. To date, MC4 has more than 21,000 systems in the field and has trained more than 22,000 deployed healthcare professionals throughout Iraq, Kuwait, Afghanistan, Qatar, Europe and South Korea with more than 2.5 million electron health records being used on the battlefield. Two databases are available to help provide information in the field. One database is Micromedex with information on medications and poisons, and the other database is MEDIC with information on worldwide diseases and environmental health risks. Both of the databases are located on MC4 systems. The Electronic Information Carrier a wireless electronic medical record including secure wireless, USB connection, and increased storage is used as part of the Future Force Warrior and the Warfighter Physiological Status Monitoring System. The EIC interfaces wirelessly with the MC4 handheld. The MC4 Research Program is developing pharmaceuticals, and medical devices to help first responders. The Combat Casualty Care program collaborates with the Office of Naval Research Casualty Care and Management Group and the Biomedical Initiative Steering Committee to work with the Land Warrior Future Force Warrior program. Autonomous Combat Casualty Care (ACCC) will be important to use in the battlefield to extract, treat and evaluate injured soldiers. In the future, ACCC will be able to locate casualties, diagnose traumatic conditions, provide life saving treatments, and evacuate the injured. The MC4 program now has software able to monitor medical supplies so medical units remain stocked. Uses can look online for information on supplies, order, and track the order. MC4 has a suite of software called DCAM which allows users to research requirement, view catalogs, and submit orders to their suppliers while maintaining an inventory database in the combat zone. Doctors in Iraq are using voice recognition successfully in clinics and operating rooms. The technology is being used to record patient care and capture surgical procedures electronically by using the MC4 system on a laptop. By synching the voice recognition software known as Dragon Naturally speaking medical version 9.5 with the MC4 system, doctors are able to cut documentation time in half by talking at about 120 words per minute. The system is able to handle up to 140 words per minute. The software saves time especially when there are mass casualties.

Radiology System The Army uses the Philips Digital Radiography System to manipulate and transfer photos using a digital camera. However, instead of a photo of a face or an arm, the image produced is a radiograph showing bones and joints. The radiologist takes the image, and stores the data onto an imaging plate where the plate is placed into a processor. The data is then transferred, while a laser scans and converts the data to a digital image, and once the image is in the computer, the radiologist can read the image, pass 128 Federal Activities in Telemedicine, Telehealth, and Health Technology

this information on to the surgeon, and copy it to a CD. The CD goes with patients as they are transferred to the rear for follow-on-care.

DDMTF The Forward Deployable Digital Military Treatment Facility (DDMTF) has four subsystems, including wireless telecommunications, digital imaging network systems, distributed video, and the Theater Medical Information System. The system is housed in 20x30 foot tents with a lab, a two-bed emergency room, an intensive care unit, patient ward, a pharmacy, a sterilizing area, and a patient administration area. The equipment includes a ruggedized portable x-ray machine, water purification and distribution system, a portable ultrasound unit, and the SMEED, a platform that attaches to a standard patient litter to hold portable medical equipment.

Simulation Tools The Army is researching existing and emerging technologies used in simulation and modeling to produce accurate casualty rates and patterns (particularly wounding patterns). Plans for the future, include developing open source standards for interoperability, studying the serious side of entertainment to see if the techniques used to play games can be applied to medicine, identifying and developing technologies for interactive media, supporting open source/architecture standards, facilitating convergences between S&TT research areas and surgical robotics, and doing research on virtual reality applied to behavioral health. The Human Patient Simulator (HPS) is a full sized medical mannequin with dilating pupils, breathing and heart sounds, palpable pulses and realistic reactions to medication. The HPS and the portable METI Emergency Care Simulator trains about 3,500 students a year ranging from non-medic combat lifesavers to doctors and physicians assistants. HPS was developed at the University of Florida in the College of Medicine to train anesthesiologists and now has 150 interactive mannequins being used in military training centers. The Laerdal SimMan System is in service with the Army, Navy, Air Force and the National Guard. The SimMan provides carotid and femoral pulses, variable blood pressure, and heart and lung sounds, and responds to treatment in real-time. Another example, the CathSim Vascular Access Simulator helps healthcare providers maintain skills needed to start an IV or draw blood, and creates a wide range of virtual patient types, ages, and complications. The Virtual Laparoscopic Interface simulates instrument motions associated with minimally invasive surgical procedures and allows the motion of a pair of surgical instruments in three-dimensional space. The Laparoscopic Surgical Workstation simulates the actual surgical requirements of strength and haptics necessary to replicate lifelike surgical experiences. The Simulation Technology Applied to Trauma Care (STATCARE) provides game-like scenarios with a physiologically responsive pharmakinetically reactive patient who gets better or worse with treatment. The on screen patient responds to pain and manifests vital signs and symptoms. Partial Simulators such as the VIRGIL chest trauma training system, a partial thorax mannequin, teaches medics how to insert a chest tube. Linked to a notebook computer, it enables a trainee in the field to diagnose the virtual patient on screen and lets the trainee practice inserting the tube in the mannequin. TATRC is working with MIT researchers on the Tissue Measurement and Property Sampling Tool 129 Federal Activities in Telemedicine, Telehealth, and Health Technology

(TEMPEST) to better define the feel of living issues. Other work is investigating high fidelity graphics for interactive training media.

Specialty Medical Augmentation Response Teams TATRC supports Specialty Medical Augmentation Response Teams (SMART) at each of the six major regional medical centers. The goal is to provide short duration medical augmentation to help local, state, federal and defense agencies and medical teams respond to disasters, provide civil military cooperative actions, and provide humanitarian assistance in disasters and terrorist attacks. The teams have expertise in triage, advanced resuscitation, trauma management, emergency operative support, nuclear, biological and chemical casualties, medical command control, communications and telemedicine systems, and evacuations. The Army is using SMART-MC3T a combination of specially trained personnel equipped with technologies and reference materials to provide immediate medical command, control communications, and telemedicine services from deployed field sites to other SMART teams, to civilian, military responders, agencies, as well as medical centers. The system is particularly effective in medical response to mass casualty situations. Teams staffed with doctors, nurses and medics are now using upgraded equipment, such as satellites to consult on cases and let replacements know just what equipment is needed. The original equipment for the SMART-MC3T teams was heavy with many pieces and difficult to assemble. The new equipment weight has been reduced from 112 pounds to 86 pounds and now fits into an airplane’s overhead bin.

Technology Transfer Activities The technology transfer pipeline for technologies is full and promising with biointelligence technology investment increasing dramatically. The Federal Laboratory Consortia, Pacific Telehealth HUI, along with universities such as Columbia (CIE), Drexel (CIMERC), University of Pittsburgh, University of California LA (CASIT), and USUHS have or are doing ongoing work with TATRC. Some of the Collaborations and Partnerships efforts include:

• TATRC working with T5 on a decentralized wireless communication systems to communicate with hospitals, helicopters, and to produce smart highway systems to map out the best route to a disaster scene and back to the hospital • TATRC administering a contract for $750,000 to Stottler Henke, a software and consulting firm to develop artificial intelligence technologies to make training systems more effective and eliminate the need for on-site simulators • TATRC working with the National Biocomputation Center at Stanford University to develop wireless sensors globally to monitor and transfer data in order to track disease outbreaks in Vietnamese streams, Hawaiian rainforests, and Ethiopian villages • Mercy Home Health is working under a grant sponsored by USAMRMC, to examine the use of remote physiologic data to monitor non-emergency home care setting. Medical devices collect blood pressures, take temperatures, heart rates, respiration, oxygen saturation, and a three-lead ECG and a stethoscope are able to perform lung assessments • TATRC working with the other services in joint medical technology research. The plan is to pursue closer relations with the CINC surgeons, specifically CINC Joint Forces Com- 130 Federal Activities in Telemedicine, Telehealth, and Health Technology

mand, and examine the possibilities for closer relationships with DARPA in the areas of medical technology R&D • The Multi-National Telemedicine Aid Project provides advanced healthcare to underserved and remote areas via satellite. The testbed sends a network of healthcare providers to military sites not only in the U.S., but also to sites in the Republic of Georgia and the Ukraine. High resolution diagnostic imaging, computer based EKG, using micro cameras with options for endoscopic exams, transferring x-rays and other diagnostic records and heart lung and blood flow sounds, providing access to global databases, and providing for medical education is available. • The Center for Military Biomaterials Research (CeMBR) supported by industry is researching biomaterials solutions to treat trauma in the areas of wound care, severed nerves, bone fractures, and the program is using diagnostics and blood vasculature/homeo- stasis. In the future, research will be done on dermal vaccines. CeMBR industry members come from medical device start-ups, midsize medical device companies, major corporations, associated research centers, production and fabrication groups, a law firm, and participating venture capital groups • The Bioengineering Institute at the Worcester Polytechnic Institute funds the Center for Untethered Medicine to develop a real-time troop monitoring system using sensors and wireless communications technologies, to track health data, and assess injuries from a distance to be coupled with a wearable ultrasound imaging system. Researchers are developing low level wearable vital sign sensors with human machine interfaces to enhance ultrasound imaging systems, and developing field computer communications and positioning networks • Robotic Surgical Tech Inc. a Columbia University spinout company received support from TATRC to develop a robotic scrub nurse to be used in the OR to directly assist surgeons. • CERMUSA at St. Francis University works to improve medical care in education for remote or medically under-served areas and developed the FREC-M ambulance to provide services to the community. CERMUSA partnering with TATRC developed the Mobile Communications Platform a vehicular data and seamless integrated communications system to use in rural areas. TATRC also partnered with CERMUSA to work on the REMeD-D system to help the civilian and military response to WMD in rural areas • Research at IBNAM focuses on developing bio-nanotechnology for wound repair, soft tissue engineering, and biosensing with funding from TATRC. IBNAM’s new facilities are located at the Robert H. Lurie Medical Research Center at Northwestern University

Technology Transfer Partnership Intermediaries DOD Tech Match (http://www.dodtechmatch.com) enhances industry/university interactions with DOD. The web site has information on opportunities, patents, labs, success stories, and lab contacts. Tech Link (http://www.techlinkcenter.org) helps DOD and NASA commercialize leading edge technology by partnering with private companies for the licensing, transfer, development of technology. First Link (http://www.DoDFirstLink.com) focuses on first responder needs by supporting commercial pathways between DOD technologies and private industry. RTI International (http://www.rti.org/technology) offers commercialization support services spanning multiple technology areas. 131 Federal Activities in Telemedicine, Telehealth, and Health Technology

Fort Detrick Technology Transfer Initiative http://www.marylandtedco.org/tedcoprograms/fdtti.cfm The Maryland Technology Development Corporation (TEDCO) and the Frederick County Office of Economic Development contract with USAMRMC to help transfer technology by awarding a maximum of $50,000 in support of technology development.

Fort Detrick Business Development Office http://www.fdbdo.com The Fort Detrick Business Development Office is the place to contact for further information on opportunities and partnerships. Information is provided on upcoming contracts, plus the Office conducts workshops. FDBDO manages the Advanced Acquisition Forecast Contracting Opportunities with Ft. Detrick, Fort Detrick’s partners, and other Department of Defense and Federal government organizations. The information is posted for potential contactors to find subcontractors, postings, partners and proposal preparation information.

National Integrated Biodefense Campus The Army Medical Research Institutes of Infectious Diseases at Ft. Detrick and Chemical Defense at the Aberdeen Proving Grounds are going to be replaced along with critical parts of the Center for Health Promotion and Preventive Medicine. A new partnership will be put in place at Ft. Detrick at the National Integrated Biodefense Campus to include partners and new facilities from NIH, Department of Homeland Security, and USDA.

TATRC West Coast Office TATRC has a West Coast Office to help TATRC concentrate on building international relationships with NATO partners, the European Union nations, and with Asian partners. Secondly, technology transfer enables government funded start-up projects to become useful commercial entities since there are western regional technology centers like Silicon Valley.

Walter Reed Army Medical Center http://www.wramc.amedd.army.mil WRAMC was scheduled to close as early as 2010 according to the Base Realignment and Closure recommendations, but it will take several more years, since several new buildings are being built in Bethesda and in Virginia to house all of the facilities. Under the Department of Defense plan, many of the services will be transferred to the Naval Medical Center in Bethesda and when the new facility is completed and the facility will be renamed the Walter Reed National Military Medical Center. Patients with complex or critical cases will go to the Center that will house the hospital’s legal medicine department, pathology services, contract administration, quality assurance, and the control for second opinion consultations worldwide. The tri-service Walter Reed Center at Bethesda will be a worldwide military referral center and will work closely with the Uniformed Service University of the Health Sciences. Primary and some specialty patient care will be moved to a community hospital to be built in Virginia. However, at the present time and on the present campus, WRAMC is using electronic wireless 132 Federal Activities in Telemedicine, Telehealth, and Health Technology

handheld devices to communicate with the pharmacies, transmit x-rays, dictate patient notes, and provide access to patient records. Data can be pulled to find patients at WRAMC that are developing nosocomial infections, and the clinical information is electronically sent to the WRAMC Infectious Disease Service alerting them to potential and costly infections that need to be identified and treated early.

Tracking System WRAMC has developed the Military Medical Tracking System (MMTS) to schedule appointments, and track documents. The system pulls information from DOD health networks with electronic health records, in-patient data, and other records to see of a soldier should be discharged or go back on active duty. WRAMC is upgrading computer workstations and individual computer accounts to use smart card ID technology. CAC readers allow workers to log onto their computer by swiping their card, and then entering the PIN, and then PKI enabled email is digitally signed or encrypted.

HealtheForces HealtheForces, the web-based clinical application gives information on the soldier’s health status, satisfaction with care, the percentage screening positive for depression, and data on over 300 elements to provide feedback on patients and their quality of life. The system provides a review of the information in AHLTA, but it is also a data repository for the electronic patient record system.

Rural Health Marshall University is working with WRAMC to adapt technology to help provide healthcare in rural West Virginia. Walter Reed is researching and developing new technologies needed for rapid patient diagnosis and treatment.

Psychiatry Services WRAMC uses face-to-face consultations and video teleconferencing (VTC) to provide mental healthcare for children and has surveyed parents to see if they feel that the VTC services are as effective as face-to-face (FTF) encounters when treating mental problems. To do this, the WRAMC Human Use Committee surveyed and conducted interviews with 100 FTF parents and 40 VTC parents. There is a growing use of video teleconferencing in general psychiatric and civilian forensic psychiatric practices and in military forensic cases, but legal issues need to be resolved. In 2009, WRMC treated the first behavioral health patient with a “Transcranial Magnetic Stimula- tion Therapy” device. The TMS Therapy device treats depressed patients who have not benefited from antidepressant medication. A device is placed on the patient’s head where short pulses of MRI strength magnetic fields are aimed at the structures in the brain involved in mood regulation.

Walter Reed Army Institute of Research http://wrair-www.army.mil Forest Glen Annex The Forest Glen Annex in Silver Spring MD will remain open and become one of six Joint Centers of Excellence in Biomedical Sciences, and house the Joint Center of Excellence in Infectious Disease 133 Federal Activities in Telemedicine, Telehealth, and Health Technology

Research. Some of the research currently done at WRAIR will be dispersed to the Aberdeen Proving Ground and Fort Detrick in Frederick MD to Fort Sam Houston in Texas and some other bases in the county. The Simulation Center at Forest Glen Annex will expand to provide medical students with a more authentic learning environment. The computer system is being upgraded to allow for more realistic experiences.

Telemedicine Directorate http://telemedicine.wramc.amedd.army.mil The Telemedicine Directorate provides clinical applications, both real-time and store-forward technologies to provide consultative support to remote sites. The Directorate is able to provide e-mail consultations, distance learning, provide internet-based applications in dermatology, echocardiography, nuclear medicine, sleep medicine, home health care, hepatitis C, dentistry, podiatry, surgical mentoring, cardiology, pulmonary, and oncology. Video conferencing capabilities provide consultative support for the tumor board, mental health, and nutrition care. The WRAMC Tele-Neurosurgery Department established a neurosurgery Telemedicine Center of Excellence to direct patient care and provides consultation services and also consultations to the 31st Combat Support Hospital in Afghanistan. Video teleconferencing and web-based technology supports NARMC and AMEDD neurosurgery patient needs. Four sites are set up within NARMC. The neurosurgery program provides instantaneous tele-neurosurgical consultations to four WRAMC satellite hospitals and clinics in NARMC. A dedicated Neurosurgery VTC station and a 24-hour accessible web-based station using the WRAMC dial-in service are available. The tele-neurosurgical hub enables far forward physicians in overseas locations to have immediate access to consultation and telementoring to aid them in caring for soldiers with head or spinal injuries. Telemedicine research focuses on several projects:

• The Clinical PSA User Assessment project to look at the usefulness and usability for handheld computing devices • The Galaxy Image Compressor to develop ultra-compressed images • The Video Bridge Support program to handle up to 24 users with multiple configured options

Some of the other projects include: • The Center Defense and Veterans Brain Injury Center at Walter Reed is working on ways to help patients with TBI. They are using telemedicine to do cognitive assessments, provide information, teletherapy, real-time video visits, video nursing supervision, manage medications, provide cognitive therapy, speech, and physical therapy, and provide training. Other specialty groups such as dermatologists and ophthalmologists are consulted outside the Center • Using a web-based e-Health Portal to make appointments, order refills, and provide basic patient information • Restoring hearing using a cochlear implant that simulates sending acoustic sound waves via electrical signals to the brain • Diagnosing soldiers in the Middle East with parasitic skin diseases using telemedicine. 134 Federal Activities in Telemedicine, Telehealth, and Health Technology

• Developing a wide array of subspecialty pain management services using low bandwidth technology • Taking blood pressure and doing heart rate screening using the CSI Health Station located in the fitness center. The system has a Personal Medical Record feature to allow users to compile and store test results from the health station, physician office visits, hospitalizations, and prescription histories • The WRAMC Coumadin Project evaluates patients on the medication by doing self-testing and uses remote monitoring, with a web-based programmable device connected to the participant’s home telephone • Evaluating phalangeal fractures by using digital video imaging and radiograph transmission in making a remote diagnosis • WRAMC connects multiple army hospitals to the eICU and connects ICU patients to a remotely managed eICU command center staffed with intensivists providing proactive care. • Using desktop VTC systems to conduct visual exams on patients with hepatitis C, and manage patient compliance with anti-viral medication schedules • Using the virtual tumor board program to allow remote, rapid, and cost effective access to multiple lung cancer specialists • Providing distance learning support for clinical consultations, patient education, physician education, and administrative video conferencing • Managing acute strokes by doing telestroke consultations • Providing digital non-mydriatic fundus images to diagnose diabetic retinopathy from a remote location. Digital, non-mydriatic photographic images of the fundus are taken at various outpatient clinics, and transmitted via the internet and read by an ophthalmologist at the Center. • Doing a computerized assessment of neuropsychological functioning as well as develop a uniform database system with electronic data transmission capabilities • Using tele-echocardiographs to use a digital format for echocardiographic studies to be transmitted over the internet. • Using a digital store-and-forward nuclear medical consultation system that is small and easy to transmit. • Developing telesurgery mentoring on a telesurgical program between WRAMC, Fort Detrick, and Johns Hopkins University. • Using technology to enable U.S. Army, Navy, and Air Force dentists to send consults, including images to specialists, where the specialists can review the consults and provide diagnosis and treatment. • Doing a gait analysis using a web-based teleconsulting software program • Developing a web-based automated mental health intake system plus other telemental health services in terrorist or disaster events with both children and adults. • Establishing a joint program with George Washington University, and Johns Hopkins University to develop a medical surveillance system for the Washington D.C. area to link trauma and health care delivery centers • Using a remote home-based cardiac rehabilitation program for post operative CABG surgery patients 135 Federal Activities in Telemedicine, Telehealth, and Health Technology

• Using telemedicine to consult on the long term outcomes of discharged burn patients treated at the Burn Unit

Human Bio Specimen Network The U.S. Military Cancer Institute is expanding cancer research efforts throughout the DOD healthcare system. The Human Bio Specimen Network, a bio tissue project targets DOD cancer research efforts. There have been multiple tissue banking projects already started at WRAMC and other military centers in DOD. The project will integrate biological sample storage and the data warehousing of patient information. The network provides more resources to help military medical researchers look for common trends and other clues in the fight against cancer, and find a reasonable, cost-effective way to support research that requires tissue specimens. The idea is to bank hundreds of tissue specimens for future scientific research, so that researchers can find tissues for rare tumors and make advances.

Telepathology The Army has a shortage of pathologists and uses telepathology to enable pathologists to do more with less, while improving the quality of patient care. The telepathology system uses modified microscopes equipped with computerized servers to control movement. The basic system has a robotic microscope mounted with a CCD camera, image grabber, and desktop computer using the windows operating system. There is an internet connection between sending and receiving sites with a workstation at the receiving site equipped with a high quality monitor to view images. A camera sends real-time images to the computer. The microscopes do everything from adjusting magnification power, to moving the slide around, to viewing the entire specimen. These images are then transmitted over the internet through secure Army networks back to Walter Reed or to the Armed Forces Institute of Pathology for closer examination.

Medical Applications Center The researchers at the Medical Applications Center use computer technology, scanning technology, and 3D technology to help manage medical treatments for patients. Because the technology is so precise, the technology can reduce the time for surgical procedures and enable surgeons to be more precise when removing tumors. Surgeons are studying CT scans and MRIs to see a series of images in small slivers at a time, and a process called stereo-lithography takes these images and converts the images to 3D technology so that the physicians can see all of the data at one time. Using this technology and having 3D models enables surgeons to better understand surgical problems. The system is in use at WRAMC, the National Naval Medical Center in Bethesda, and other facilities in the National Capital Area and the North Atlantic Regional Medical Command.

Tripler Army Medical Center http://www.tamc.amedd.army.mil Tripler’s congressionally funded program, the Pacific Island Healthcare Project was created to 136 Federal Activities in Telemedicine, Telehealth, and Health Technology

extend the expertise available at TAMC to the medically underserved peoples of the Pacific Basin, while at the same time providing graduate medical education cases for the medical and surgical residents in training. The web-based electronic consultation and referral system makes it possible for physicians in the Pacific to consult with specialists and sub-specialists at TAMC. With the use of standardized forms, the medical director is now able to quickly assess and triage consultations from distant sites. The Pacific Regional Medical Command at TAMC studies telecommunications and technology capabilities in the region, and manages a geographically complex patient care environment using VA and DOD clinically driven multi-disciplinary teams. Care is provided to the Federated States of Micronesia, Yap, Kosrae, Chuuk and Pohnpei, the Republic of Palau, and the Republic of the Marshall Islands, plus patients are seen in American Samoa and the Commonwealth of Northern Marianas Islands and Guam. There has been a joint effort to wire a telemedicine network to provide remote critical care support to the islands. TAMC with the University of Hawaii will mange the remote monitoring and support system.

Digital Programs The Army is working on a digital echocardiology program to improve patient care and reduce costs. Presently, the cardiology service at TAMC reads echocardiograms performed in remote locations recorded on videotape and mailed for interpretations. The turnaround time for these echo interpretations is three to four weeks. The digital echocardiology program has an echocardiography network where echocardiograms are digitally recorded by a technician in Guam, Japan, or Korea and then the echocardiograms are sent to a cardiologist for interpretation at TAMC within 24 to 48 hours. The Army is interested in the development of digital radiographic systems for remote diagnosis applications in the region, with several services interested including the Marine Corps, Air Expeditionary Force, and the Army. The Remote Access to Medical Specialists (RAMS) program is developing a fully digital radiographic system which will be compact, light weight, and have the capability for the transmission of digital image data for remote diagnosis. The e-ICU system at Tripler is the first military medical center to use telemedicine technology for long distance ICU care. Critical Care specialists are able to examine, diagnose, and monitor intensive care unit patients with the help of local doctors at military installations in Guam and Korea.

DOD/VA Interoperability Project DOD/VA Interoperability Project uses a system to enable two-way communication between the VA’s VistA and DOD’s electronic patient record system. The system allows physicians at TAMC to enter prescriptions in DOD’s Health Care System and then transmit the prescriptions electronically to VistA.

Voice Therapy Project TAMC is evaluating the clinical appropriateness, technical acceptability, and operational effectiveness of delivering voice therapy via video teleconferencing to remote satellite clinics. Researchers are looking at the patient’s attitude toward the technology and the patient’s access to care.

Internet Tumor Board General surgeons are able to submit cases to the medical center once a week using telemedicine to discuss cancer cases and treatments. This helps the surgeons provide better care and avoid costly aero- vacs to Tripler for care. 137 Federal Activities in Telemedicine, Telehealth, and Health Technology

Pacific Telehealth and Technology Hui http://www.pacifichui.org TAMC and the Veterans Affairs Medical and Regional Office Center in Honolulu have established a partnership called the Pacific Telehealth and Technology Hui to improve the quality, accessibility, patient satisfaction, and cost effectiveness of healthcare services through emerging and existing telehealth technologies. The VA/DOD Pacific Hui is working on telehealth, clinical evaluations, distance learning, and technology transfer.

School Immunization Program The Hui is leading a statewide effort to launch an online reporting system for tracking immunizations of Hawaiian school children. The Hawaii State Department of Health Immunization Branch has adopted the web-based system to use in schools statewide, and CDC and the Hawaii Department of Education are helping in the effort.

Open Vista Hui reports that many healthcare software development and medical research organizations have executed licenses and downloaded the Hui “Open Vista” software from their web site since the electronic healthcare enterprise information system was launched. Hui “Open Vista” is an open source fully integrated enterprise healthcare information system based on the VA’s VistA system. Hui’s goal in launch- ing “Open Vista” is to enable non-VA hospitals and clinics throughout the Pacific region and beyond to implement a healthcare information system free of licensing costs. The development and release of “Open Vista” has been funded and managed by the Hui in collaboration with Medsphere, a private company, and Word VistA a professional organization of VistA software developers. To increase the use of “Open Vista”, a coalition of healthcare organizations are doing an 18 month research study to find ways to implement open source EHRs in additional critical access hospitals and rural clinics. This initiative will serve as the test bed for Hawaii’s state hospital system.

Joslin Vision Network The Joslin Vision Network (JVN) initiative treats remote diabetic patients including those with diabetic retinopathy at centralized subspecialty centers. A joint research program has been established between the JVD, TAMC, and the VA to investigate the efficacy of new technologies in the detection of diabetes and diagnosis of diabetic retinopathy.

Pediatrics ECHO-Pac an internet consultation network for pediatricians caring for military family members across the Pacific Rim enables rapid access to pediatricians and to pediatric sub-specialists. The consult network includes 244 active providers and 22 support personnel. The consults have resulted in more than 5,000 pediatric and pediatric surgical subspecialty consults and follow-up visits. The Pediatric Cardiology Telemedicine Trial is implementing a process to allow imaging studies and other necessary information to be sent electronically to the surgical and medical teams prior to a 138 Federal Activities in Telemedicine, Telehealth, and Health Technology

pediatric patient’s medical evacuation from one site to another. Hui is designing a web-based system to digitize and transmit echocardiographs via the internet using store-and-forward technology. The Community Pediatric Research, Teaching, and Service Project has implemented a collaborative community pediatrics venture to form a fellowship in community pediatrics and provide a pediatric residency rotation in primary care sites in Hawaii along with telehealth consulting services.

Path System The Path System is a web-based teleconsultation application that enables primary care physicians to consult with medical specialists over the internet in asynchronous time. Based at Tripler, PATH links to a network of providers at medical treatment facilities in the west Pacific and Northwest Pacific regions and the 18th MEDCOM in South Korea. Hui has used the PATH technology to help the Kapiolani Medi- cal Center for Women and Children. The Hui has partnered with Hawaii’s Primary Care Association and Moloka General Hospital to assist in teleconsulting services to federally funded community clinics and hospitals.

Virtual Reality Behavioral Health HUI working with DOD, VA, and other agencies is developing virtual reality technology for behavioral healthcare and virtual reality applications to be used by psychologists with patients that have psycho-physiologic disorders and under stress. HUI with the University of Hawaii is developing computing technology to provide three-dimensional manipulations and computer generated simulations to teach medical students. Hui is using virtual reality therapy to treat post-traumatic stress disorder in soldiers returning from Iraq and Afghanistan. The research is funded as part of the Warfighter Mental Health Pro- gram at the Medical and Biological Science and Technology Division of the Office of Naval Research.

Biosensors Hui has launched two research studies to look at changes in human biologic responses as they relate to patterns of behavior with participants wearing wearable sensors. The study is looking at patterns of tobacco use among smokers to develop new approaches to smoking cessation and tailor interventions to individual behaviors. The program is also evaluating team play in a collaborative gaming environment to determine if the patterns of individuals in a group vary with overall team performance.

Some of the Other Projects • Hui has established the Hawaii Medical Informatics Collaboration to focus on projects that use health information technology and shared healthcare data • Hui has a joint venture with DOD and the VA to use a portable medical digital radiography system • Hui manages the Hyper-Spectral Diagnostic Imaging technology for the purpose of detecting and localizing pre-cancerous lesions • Physicians from remote locations use electronically monitored intensive care units to consult in real-time to treat critically ill patients. • Federal Clinical Telehealth Project improves access to high quality care and consultative services to federal beneficiaries in the Pacific region. The Hui serves as a facilitating agent in developing a unified DOD/VA clinical telehealth network 139 Federal Activities in Telemedicine, Telehealth, and Health Technology

• The HeartSounds project a collaborative effort of Hui and the U.S. Naval Hospital in Guam, and the U.S. Naval Hospital in Okinawa is using telemedicine to diagnose heart murmurs in pediatric patients • The Augmentation of Special Needs Services and Information to Students and Teachers (ASSIST) program assists elementary schools using telemedicine to provide medically related diagnostic and intervention services to special needs children in the school setting • The Simulation Imaging and Biosensor Research initiative is a collaborative effort with Hui and TAMC, the John A. Burns School of Medicine at the University of Hawaii, and the University of New Mexico, School of Medicine. • The video otoscopy II project digitizes video images of the eardrum and stores and analyzes these images via a web interface to be evaluated by otolaryngologists and audiologists Fort Gordon http://www.gordon.army.mil

Center for Total Access The Center for Total Access (CTA) a joint service effort located at Fort Gordon, Georgia, is actively involved in medical communications and in several telemedicine care areas. These areas include telecriti- cal care, telepathology, and specialized treatment services such as cardiology. CTA is developing medical diagnostic imaging systems. Projects • CTA is collaborating with WRAMC and TATRC on web-based teledermatology services • The Clinical Neurology Telemedicine Support System provides services to military treatment facilities without a staff neurologist to help medical forces operating in austere environments • CTA is developing a network of computer-based digital devices to electronically provide radiology services at regional medical treatment facilities • The Georgia Institute of Technology, the Medical College of Georgia, and the Center for Total Access provide virtual house calls to chronically ill patients • The MedSurv module, a component of the Special Operations Medical Diagnostic System (SOMDS) collects specific data elements at the point-of-care using handheld devices functioning both synchronously and asynchronously with a centralized database • CTA established a teledentistry network • CTA has a Combat Trauma Patient Simulator (CTPS) simulate the emergency medical treatment process for combat trauma injuries • The Child Psychiatry Clinic at Eisenhower Army Medical Center uses video teleconferencing equipment at remote sites, and lets health clinics and hospitals conduct virtual patient sessions using real-time video transmissions • Digital cameras are placed inside military emergency ambulances, connected to a wireless network access radio, data goes to a second wireless network inside a healthcare facility, converts the signal from digital to video, and displays the data on a color monitor 140 Federal Activities in Telemedicine, Telehealth, and Health Technology

• CTA and the Army School of Aviation Medicine are developing a standardized effective method for educating and maintaining standards of care for students in Flight Surgeon or Flight Medic training

Homeland Security The Office of Homeland Security, Army Medical Command (MEDCOM) has oversight for all medical support applications used by the Regional Medical Commands to support the Homeland Security mission. CTA evaluates medical technologies for use in military healthcare.

Fort Sam Houston http://www.samhouston.army.mil U.S. Army Medical Information Technology Center http://usamitc.amedd.army.mil The U.S. Army Medical Information Technology Center (USAMITC) provides the infrastructure for a single Army medical network and is responsible for IM/IT design and development. Through six global messaging centers, information technology services are provided for electronic mail, mobile devices, data sharing and access to applications, security compliance, and integrated joint enterprises. The Center operates the Medical Network Operations Security Center monitoring 24/7 to look for any vulnerabilities concerning medical networks, plus maintaining the Virtual Private Network. In other projects, the Center operates an integrated help desk program, works with the Walter Reed Army Medical Center and the National Naval Medical Center to share access to the Center’s surgery scheduling system, plus works with MHS to integrate AHLTA into healthcare facilities. USAMITC has improved their IT service management processes. Their system is built on the information technology infrastructure library or ITIL which is considered to be an excellent approach to IT service management. The ESD has been deployed throughout the Army Medical Command infrastructure. The system is a consolidated standard, stable and secure service desk that reduces redundancies and achieves cost savings for the command The ESD deployment is scheduled for completion by March 2010.

Joint Center for Excellence Battlefield Health and Trauma Research Center DOD is building a combat casualty care and trauma research program to be housed at Ft. Sam Houston. The Center enables research and development experts scattered throughout the nation, to centralize efforts to improve efficiency. The emphasis is on delivering the best care for warriors who suffer life-threatening injuries on the battlefield.

San Antonio Military Medical Center http://www.sammc.amedd.army.mil Brooke Hall Medical Center and the Air Force Wilford Hall Medical Center are now part of the San Antonio Military Medical Center. The Brooke Medical Center houses an Army and Air Force 425 141 Federal Activities in Telemedicine, Telehealth, and Health Technology

hospital bed center. A world class outpatient and ambulatory surgery center is located at the Wilford Hall Medical Center at Lackland Air Force Base.

Brooke Army Medical Center Brooke Army Medical Center is the home for the “Center for the Intrepid” to provide the highest quality of comprehensive outpatient rehabilitation. There are several programs at the Center such as the Amputee Patient Care Program, Limb Reconstruction/Limb Salvage Program, and the Advanced Burn Rehabilitation Program. The physical therapists evaluate, diagnosis, treat, soldiers that have sustained trauma and or illnesses. The Center also provides comprehensive psychiatric support services to amputees and their families, provides help on doing daily activities, has a laboratory that analyzes amputee walking to help physicians and physical therapists adjust treatments.

Institute of Surgical Research http://usaisr.amedd.army.mil The Institute of Surgical Research is located at the Brooke Army Medial Center at Fort Sam Hous- ton. The facility has a multidisciplinary staff of over 250 personnel both military and civilian that provides state-of-the-art trauma, burn, and critical care. The Combat Casualty Care Research Mission has six basic research areas to concentrate on resuscitation, bone tissue injuries, soft tissue injuries, trauma informatics, and clinical trauma. A second amputee care center has been established to provide state-of- the-art care to include a full range of amputee patient care at one site. Orthopedics, physical medicine and rehabilitation, occupational therapy, physical therapy and prosthetics as well as social work and VA counselors are provided. Robotic technology is being used in the ISR burn intensive care unit. Eighty percent of the physicians, nurses, residents, and families of the patients at ISR are very satisfied with the robot’s use. TATRC has deployed the RP-7 Remote Presence Robotic System developed by InTouch Health at Brooke which enables the doctors to log on to the robot via a laptop and communicate directly with the ICU.

Madigan Army Medical Center http://www.mamc.amedd.army.mil Madigan Army Medical Center in Tacoma Washington has launched MiCare, the Military Health System’s prototype personal health record. The system was developed as a pilot project in partnership with Microsoft Corp and Google. Beneficiaries that choose to enroll in MiCare will have access to their demographic information, active medication lists, allergy data, lab results, radiology results, personal problem list, past visits, upcoming appointment, and inpatient/outpatient documentation from AHLTA.

Proposed Army Center for Applied Biotechnology The U.S. Army is looking for interest from the commercial biotechnology industry, academia and other government agencies to form a consortium to develop biotechnology-based solutions to a broad range of Army and DOD requirements, and operate other centers on other R&D activities beyond basic research, concerning health monitoring, gene-expression monitoring for performance enhancement, bioinformatics, and computational biology. 142 Federal Activities in Telemedicine, Telehealth, and Health Technology

Army SBIR/STTR Program

http://www.acq.osd.mil/osbp/sbir The Army’s Small Business Innovation Research (SBIR) program has spent over $1 billion in research and helps the small business community meet the Army’s research and development objectives. Companies are able to develop technologies, products, and services to commercialize through sales in the private sector or back to the government. DOD has issued solicitations with two topics of interest to the healthcare and medical community. One topic was to do research on a medical surgical information system, and the other topic was to develop virtual reality tools for training and rehabilitating patients using advanced prosthesis. TATRC has SBIR projects working on advanced medical robotic systems to augment healthcare capabilities. The final product will be a robotic assistant to take direction from nurses to help lift patients. Some of the topics for previous solicitations have included developing ultrasound to use to diagnose traumatic brain injury in the battlefield, developing telesurgery capabilities, protecting the military from chemicals and bio agents using robotics, and developing sensor networks. Funding has included such projects as 3D Volumetric Floating Image with Haptics, needle thoracentesis simulation workstation for medical training, and catheter insertion simulation for epidural anesthesia and spinal tap.

Examples of the SBIR Research • A hybrid stethoscope was developed under SBIR by Active Signal Technologies and the Army Aeromedical Research Laboratory • Cybernet Medical, a developer of biometric monitoring technology and medical devices developed a handheld Readiness Assessment Tool for the Defense Department. • Quantum Applied Science and Research Inc researched sensor artifact and noise reduction algorithms for cognitive and physiological status monitoring • Simbex developed a powered foot and ankle prosthesis for improved maneuverability

Navy Telemedicine Activities

http://www.navymedicine.med.navy.mul The Navy conducts medical research in a wide range of disciplines such as biological infectious diseases, combat casualty care, dental and biomedical research, directed energy, bioeffects, environmental health, aerospace medicine, undersea medicine, tropical medicine, marrow donor program, medical modeling, simulation, and mission support, warfighter performance, epidemiology and behavioral sciences. The Navy is coordinating telehealth business practices, making the virtual naval hospital project resources more available, and working with TRICARE, the Bureau of Medicine and Surgery, the Joint U.S. and Coalition Forces, the VA, and other federal agencies. The Navy is using telemedicine to connect doctors, using videoconferencing to perform remote mental health encounters, using a telepharmacy system, and providing remote radiographic and specialty consultations. The Navy has home health telemedicine projects enabling patients with congestive heart failure and diabetes to upload their daily weights and glucose results to their doctors. 143 Federal Activities in Telemedicine, Telehealth, and Health Technology

Teleradiology The Navy has developed a computed radiography and teleradiology program and has transitioned from film to digital medical imaging. The service has a regional radiology study archives, and provides multi-disciplinary collaboration and consultation services. Today, the Navy has a Global Digital TeleRa- diology Network that includes large deck operational and hospital ships equipped with CR/TR, teleradiology branch clinics and naval hospitals worldwide, DINPACS medical treatment facilities, and a virtual radiologist in Kefavik, Iceland and Guantanamo, Cuba. The ship the COMFORT has upgraded the DINPACS system with RadWorks software funded by the naval telemedicine business office, and the Navy has phased the software into amphibious ships, large deck ships and carriers. The COMFORT RadWorks gateway can transfer radiology studies directly via satellite to other designated fleet platforms such as aircraft carriers and amphibious ready groups. The DINPACS system allows computed radiography or plain film, CT scans, and ultrasound images stored in the web server to be transmitted to the RadWorks gateway for off-ship direct electronic transmission via satellite to shore based locations. The images are displayed at designated workstations throughout the ship, allowing onboard radiologists and other medical specialists to request or provide clinical teleconsultations worldwide.

Comprehensive Care Casualty Effort The Navy has initiated a Comprehensive Casualty Care effort to help coordinate and expedient the delivery of clinical and non clinical services. One of the initiatives under this effort is the Lean Six Sigma mapping of the casualty care process to identify areas of patient transitions, gaps in service, and unmet needs across key functional service areas. These areas include medical, pay, personnel family support, case management information technology and the disability evaluation system.

Virtual Medical Clinics The Navy has several operational virtual medical clinics such as ENT interactive clinics in TRICARE Region 9, providing virtual primary mental health in TRICARE Region 1, providing dermatology using virtual services in Europe and in TRICARE Region 3, and is working on product line multi- specialty teleconsultation web tools.

Fleet Technology The USNS Comfort and the USS Bon Homme Richard support telemedicine capabilities. The Navy wants their ships to become virtual extensions of Navy hospitals and is spreading telemedicine technology throughout the fleet. The Navy has developed the Fleet Hospital of the Future to provide a modular plug and play which adds greater flexibility to the fleet. The Navy is designing a small ten bed expeditionary surgical unit along with an even smaller four bed surgical component. These new smaller products have been imbed- ded into the Next Generation Concept Fleet Hospital. The USNS COMFORT is a prime asset within the Navy Afloat Trauma System (NATS) and serves as a primary medical treatment facility for high level care. The ship delivers care via satellites, using an information technology team to keep the ship operating efficiently. Twenty nine Navy active duty reserv- 144 Federal Activities in Telemedicine, Telehealth, and Health Technology

ists and civilians deal with the inner workings of all the communications aboard the ship as well as at remote medical and construction work sites ashore. The radio department operates the WSC-8 super high frequency satellite system to send and receive information for radio, operates the Broadband Global Area Network (B-GAN) portable satellite termi- nals, phones, and ADP. The ship is exploring alternatives for shore to ship communications, including a Ground Antenna Transmit Receive Satellite prototype which is being tested in Manta, Ecuador. The Multimedia Integrated Distributed Network (MIDN) provides telemedicine links with carrier battle groups, multiple Medical Treatment Facilities, regional clinics, and various other remote clinics worldwide. The MIDN project provides engineering support, a virtual worldwide internet help desk, clinical consultations, support to DOD referring sites, and to the Navy and Marine Corps, plus an operational testbed to evaluate emerging telemedicine applications in real-time.

Humanitarian Deployment Using Telemedicine The USNS Mercy using BMIST has gone on a number of humanitarian deployments. The medical crew goes ashore and interviews patients and then enters their vital health data into the BMIST equipped PDA. By the time, patients are admitted to the military treatment facility, their records are on file in the ship’s computers.

Small Ships The Chief of Bureau of Medicine and Surgery would like telemedicine used in small ships medical departments because small ships very often do not have telemedicine capabilities. Researchers are evaluating telemedicine networks onshore, so that telemedicine applications can be increased on small ships.

Tactical Medical Coordination System http://www.namrl.navy.mil The Navy at Fleet Hospital Three has tested a wireless communication network designed for field use to capture and display real-time casualty data, called the Tactical Medical Coordination System (TacMedCS). Eight hundred wristbands, a wireless network complete with relays and antennas, a laptop with the databases, five scanners and a server were deployed in Iraq and the system now successfully tracks patients moving through the hospital. When the patient leaves the fleet hospital, the final disposition is electronically written to the wristband.

Shipboard Non-Tactical Automated Data Processing Program Automated Medical System http://enterprise.spawar.navy.mil SAMS a versatile, automated medical support application includes several modules for tracking radiation exposure data, and monitoring environmental conditions. The system writes the health data on an electronic information carrier, and then moves the encounter information along with the individual soldier. SAMS is currently in use at over 1200 sites in the Navy and Marine Corps both ashore and afloat 145 Federal Activities in Telemedicine, Telehealth, and Health Technology

National Naval Medical Center http://www.bethesda.med.navy.mil The NNMC in Bethesda MD is a key link for information on telemedicine and telehealth in the Navy. NNMC provides for clinical, training and administrative telehealth support, and advanced digital and telecommunications technology. The National Naval Medical Center (NNMC) uses telemedicine for training and clinical services and provides regional clinical consults in dermatology, pediatrics, teleradiology, teleorthopedics, teleo- phthalmology, telemental health, telegenetics, and telepathology. NNMC also provides real-time maternal fetal medicine consultations with the U.S. Army Hospital in Landstuhl, Germany using video teleconference technology. NNMC helps pregnant women with uncontrolled diabetes that come to NNMC. They are given glucose meters and the technology that they need to transfer their blood sugar readings to the MyCareTeam database over the internet. The Center is using robotic pharmacies to process prescriptions. Before using the system, the pharmacists were filling between 500 and 600 prescriptions a day and now the output has nearly doubled. The NNMC has transitioned patient records from paper to a digital healthcare database The National Naval Medical Center’s, Division of Primary Behavioral Healthcare and Mental Health, uses electronic communications to order prescriptions, find information on laboratory workups, and enables patients to schedule appointments.

Navy Medicine Training Center The Navy Medicine Training Center (NMTC) to be located at Fort Sam Houston, Texas, will provide inter service education and training and is scheduled to open between 2010 and 2011. The BRAC requires Navy and Air Force enlisted training courses to relocate to Fort Sam Houston. The average daily student load will be about 9,000 sailors, soldiers, and Airmen in 2011.

Naval Medical Information Management Center Naval Telemedicine Business Office The Naval Telemedicine Business Office assists in identifying requirements and recommends strategies to improve operations. The NTBO is involved in:

• Providing clinical needs assessments to establish clinical guidelines, protocols, and standards • Validating requirements and needs into integrated requirements to coordinate with TMIP and TRICARE • Providing technology assessments to translate requirements into proven information technology and re-engineered business solutions • Ensuring system end-to-end interoperability across the military health system network • Providing technical support for recommended digital technologies to be used in telemedicine applications 146 Federal Activities in Telemedicine, Telehealth, and Health Technology

• Coordinating telemedicine across the Navy as well as with the other military services and federal agencies • Developing the Global Telemedicine Consultation System • Working with the dental community, on digital technologies such as computed radiography and direct radiography to replace wet film processing. Dental prototypes for direct radiography are used on a limited basis by some dental clinics both inside and outside of DOD. The efforts to manage Digital Radiography with the PACS archives are coordinated by NMLC and the MNIMC Naval Telemedicine Business Office.

Naval Medicine Online http://navymedicine.med.navy.mil The Naval Medicine Online web portal provides a single point of access to Navy medical data, news, training, and healthcare information. The site serves as a gateway for Navy personnel to conduct professional business via a personalized, needs-based user interface. Currently, there are 15 different services available on NMO for individual and command use. NMO contains knowledge tools to allow individuals to share documents and other electronic files, and to protect chat rooms to allow for secure communications with patients or other Naval Medicine personnel. A key function of NMO is the developer whiteboard, a tool that allows the software code to be placed in a secure area in order to modify the code and make improvements. NMO spans a broad spectrum of information and includes current Naval Medicine news, instant access to military directives, a search engine to locate a medical facilities, and navigational tools to link users to TRICARE Online, Navy Knowledge Online, and other military sites. With the ToolKit function, users can group favorite services for easy access. NMO also provides business services for individual commands, such as hosting web sites, providing real-time survey capabilities, and making project management software available. Users can share documents and have access to general military training. Other Navy Projects • The Medical Science and Technology Division focuses on medical therapies and protective equipment, such as laser protection systems, developing hearing conservation and restoration therapies, and does basic research in a variety of biomedical disciplines • Projects are evaluating virtual reality therapy for treating acute post traumatic stress disorder in combat and non-combat situations. • The Naval Hospital in Pensacola has implemented an anesthesia information management system into the operating rooms that is integrated with an IV medication system • The NMRS’s Biological Defense Research Directorate applies genomic technology using custom designed silicon chips seeded with millions of DNA fragments to quickly identify environmental strains of bacteria like anthrax and see if personnel have been exposed to some biological agent • The Naval Hospital at Camp Pendleton has all of the patient safety reporting applications online, so users can submit reports about errors or unsafe practices at the hospital. Other patient safety measures include using a pharmacy robot to reduce medication errors and using computerized medication carts 147 Federal Activities in Telemedicine, Telehealth, and Health Technology

• The Naval Hospital in Yokosuka Japan helps battle malignant cancers. Healthcare professionals use a national database called Acture so that doctors in the U.S. and other military bases can compare how patients with the same kind of cancer react to different treatments. All information is collected using pharmacy, radiology, inpatient and outpatient records • The U.S. Pacific Command partnering with DOD is developing real-time data streaming to collect joint service medical encounters data, and medical facility reports, by using web- based clinical consultation tools, and an advanced medical disease surveillance system • The Naval Hospital at Camp Lejeune, North Carolina with four medical schools and five remote area civilian medical treatment facilities are working on a prototype emergency medicine consultation and teleconferencing network • The Navy and Marine Corps find that the major obstacle in treating patients in remote areas is communicating to non-English speaking patients. The Multimedia Medical Language Translator permits communication between healthcare providers and the patient in more than 40 different languages using off-the-shelf PCs or laptop computers

Office of Naval Research http://www.nmrc.navy.mil Naval Institute for Dental and Biomedical Research The Naval Institute for Dental and Biomedical Research is developing a miniature laboratory light- based clinical fluorescence polarimeter to furnish miniaturized equipment and light-based fluorescence polarization assays to the fleet. The equipment can be used to rapidly aid in the diagnosis of systemic diseases, immunization status, and exposure to drugs.

First Responder Emergency Communications The First Responder Emergency Communications-Mobile (FREC-M) system developed with funding from the Office of Naval Research relies on an international maritime satellite and other communications frequencies to indicate bad weather, geographical terrain, and helps physicians at emergency centers communicate with ambulances in real-time.

Naval Medical Research and Development There are ten laboratories in the NMR&D Enterprise. Research areas include biological defense, infectious diseases, combat casualty care, dental and biomedical research, directed energy bioeffects, environmental health, aerospace medicine, undersea medicine, tropical medicine, marrow donor program, medical modeling, simulation, and mission support, warfighter performance, and epidemiology and behavioral sciences.

Naval Health Research Center http://www.nhrc.navy.mil Several programs at NHRC involve modeling, simulation, surveillance, telecommunication technologies, and measuring the effectiveness for using telemedicine to deliver services to patients in nontraditional ways. 148 Federal Activities in Telemedicine, Telehealth, and Health Technology

Modeling and Simulation Group The Modeling and Simulation Group designs and supports tools to improve clinical capability and to streamline patient treatment resources. M&S works with medical planners, providers, and logisticians to develop projects to assist in field medical services planning, systems analysis, operational risk assessment, and to determine the best course of works with the Marine action for treating a particular patient stream with the available resources. M&S develops databases and incorporates the data into software tools. The program produced MEDTAG, a field documentation device, MEDTAB a medical documentation system for medical treatment facilities, and MEDTRAK, a patient tracking system Some of the other programs at NHRC include:

• San Diego’s Center for Commercialization of Advanced Technology provides technology transition assistance to small companies working on DOD funded technologies. The program is funded by DOD through the Office of Naval Research • The Field Medical Technologies Group looks at Navy telemedicine practices and equipment used in austere environments ashore and afloat to provide care to TRICARE beneficiaries receiving primary care at remote locations. The Group integrates technologies with tri-service medical information systems, and deploys portable technologies to assist in diagnosing and treating injuries and illnesses • The Force Health Protection and Readiness program studies emerging infections, and has undertaken a joint-service Millennium Cohort Study to track 100,000 military people over the course of 21 years. The focus is to determine if military people are healthier than civilian counterparts. Information is available on the most recent deployment medical research for all service members • The Center maintains the DOD Birth and Infant Health Registry to track birth defects, and is compatible with similar surveillance programs at CDC and some state programs. Only 35 states have any kind of birth defects surveillance, however, the military can do this type of surveillance because they use standard codes. The military has the need to look harder at the data, since a growing number of women on active duty could be exposed to hazardous materials.

Naval Ambulatory Care Center Diabetic Treatment and Education Program The Naval Ambulatory Care Center in Newport R.I. has established a diabetic treatment and education program for patients. The disease management database is designed to help healthcare providers and diabetic patients deal with the illness. A team of doctors, nurses, pharmacists, and dietitians worked closely with software designers to develop the program. Information is provided on demographics and enrollment information on the type of diabetes, results of diabetic lab tests, medications, and appointments, immunization visits, and dates for the most recent eye and foot exams. The program has computerized lists to identify patients who have elevated lab results. Patients with dangerously elevated blood levels are contacted and enrolled in self-management programs. Individual patient summaries are available along with summary reports for each provider’s diabetic patient list. The database is currently access-based, interactive, and expandable. 149 Federal Activities in Telemedicine, Telehealth, and Health Technology

Medical Data Surveillance System The Medical Data Surveillance System (MDSS) provides enhanced medical threat detection through advanced analysis of routinely collected outpatient data in deployed situations. MDSS is part of the Joint Medical Operations-Telemedicine Advanced Concept Technology Demonstration Program and interfaces with the DOD Health Care system. MDSS interfaces with the SAMS database system, uses signal detection and reconstruction methods to provide early detection of changes, trends, shifts, and bursts in syndrome and disease, and signals an event allowing for early medical and tactical intervention.

Bioterrorism and Biowarfare The Navy is involved in bioterrorism, and biowarfare, detection, and identification programs. The Biological Defense Research Directorate works with other agencies on bioterrorism and biowarfare issues and provides laboratory expertise in detection and identification of threat agents. The current navy colloidal gold-based detection technology may soon be replaced by state-of-the art paramagnetic detection technology, with preliminary studies demonstrating an increase in sensitivity of 10 to 1000 times over current capabilities. Future developments will use a bio detector with rapid high throughput DNA sequencing capability, to provide a state-of-the-art ability to fingerprint bioterrorist and biowarfare agents. This capability would be able to determine the source of bioterrorist and biowarfare agents, dif- ferentiate a bioterrorism attack from natural outbreaks, and could be used to develop a genetic library of biothreat agents.

National Disaster Medical System http://www.ndms.fema.gov The Navy works with the National Disaster Medical System, a medical response partnership. The Navy’s medicine tactical medical capabilities, medical and scientific expertise, and the federal coordinating centers are working on homeland security. The Mobile Medical Augmentation Readiness Teams (MMART) uses the latest technology to provide psychiatric rapid intervention, medical services and humanitarian support to help the Forward Deployed Preventive Medical Units (FDPMU).

Defense Medical Human Resource System Internet The DMHRSi is managed by the Navy Medicine Support Center and is operational in more than 25 commands throughout Navy Medicine. The system is an internet-based application with information stored in a database that integrates education, training, readiness, labor cost assignments, and personnel and manpower data. The system standardizes medical department human resource information across all branches of the Armed Services and tracks and monitors all vacant billets, deployable personnel, training needs, manning issues at all levels and labor costs.

Navy Research Effort The Navy’s Space and Naval Warfare Systems Center Pacific (SSC Pacific) has developed “Haptic Communication Glove” technology. The technology helps to overcome communication barriers for blind and deaf people and can be used where auditory or visual communication methods are not possible. The technology enables a person to send and receive messages simply by moving fingers. Each finger is fitted 150 Federal Activities in Telemedicine, Telehealth, and Health Technology

with a sensor to measure movement and has a vibration motor to create a sense of touch feedback. Move- ments are translated into language and sent wirelessly from one glove to another glove in the form of vibrations that the receiving party feels. The glove can be used to interact with computers, the web, and even autonomous robotic vehicles. It is possible that entire books could be sent electronically using the glove.

Air Force Telemedicine Activities

http://airforcemedicine.afms.mil The AFMS has more than 40,000 healthcare professionals serving at 76 clinics, hospitals, medical centers, and in the battlefield. The Air Force telemedicine program is working on pathology, cardiology, forensics dentistry, dermatology, genomics, psychology, pediatrics ophthalmology, internal medicine, remote sensing, trauma, and the miniaturization of handheld devices. The Air Force is evaluating lightweight, portable peripheral devices such as lung spirometry analyzers, EKGs and ultrasound probes that can attach to a laptop, or even smaller computers in a “plug and play” mode. The Air Force is also working on developing computerized medical records, patient decision support, patient tracking systems, and telecommunications. Mele Associates Inc. manages 26 Congressional telemedicine programs for the SCR with a value of more than $100 million and they develop and manage the Air Force budget planning for the telemedicine projects. The company provides support for the TMIP-J software integration program. In general, the telemedicine projects managed by Mele Associates includes using IMITS for transmitting images, retinopathy screening, providing outreach to diabetes patients, telepathology, tele-echocardiology, rapid ID to detect bio agents, developing laser eye protection/detection, and developing a virtual medical trainer. Telehealth The Air Force has developed the Air Force Radiology Network (RADNET) Project to provide Dynamic Workload Allocation. The system links military radiologists via a global enterprise system. RADNET provides access to studies across every radiology department. The Telemental Health Project provides video teleconference units at every Mental Health clinic for live patient consultations. Virtual Reality equipment will be installed at six Air Force sites to use in a pilot project to help treat patients with PTSD. The Air Force and the University of Nebraska Medical Center have formed a partnership so that medical center psychiatrists are able to provide servicemen and women help via telehealth technology. The problems the troops present range from PTSD to depression and substance abuse. The UNMC Department of Psychiatry will take the lead and the services will be offered regionally to Air Force personnel.

UPMC and the Air Force Effort UPMC is studying diabetic retinopathy to try to prevent vision loss. A process for packaging and transporting digital retinal images with patient information from the site of acquisition to specialists at remote locations has been developed. The images are graded with follow-up consultations with Univer- sity of Pittsburgh Medical Center (UPMC) and the Air Force Base. 151 Federal Activities in Telemedicine, Telehealth, and Health Technology

UMPC and the Air Force are developing a multi-specialty teleconsultation system with a common platform supporting dermatology, pathology, radiology, and clinical services. Clinicians can view various types of medical information from pathology slides to CT scans as well as consult with specialists at distant locations. UPMC and the Air Force Medical Services have launched a teleradiology initiative at Wright-Pat- terson Air Force Base in Dayton Ohio. The initiative will allow AFMS sites to send imaging studies using bi-directional transmission.

Air Force Expeditionary Medical Skills Institute C-STARS Program The C-STARS program is an Air Force medical training program at the School of Medicine at St. Louis University. The goal is to prepare Air Force medics by providing hands on clinical training. The Expeditionary Medical Support unit houses a simulator with computerized sensors that react to any medical treatment. Because of the technology built in the human patient simulator, it can come to life and can die too, just like a real wounded warrior. It can breath, talk, choke, scream, the eyes can dilate and blink.

Equipment in the Field “Small footprint” teams have taken full advantage of the revolution in medical electronic equipment. Equipment that was too large to move is now carried in one hand, patient monitoring can now be done in field conditions, and a small team with backpacks can provide medical care in any corner of the world. Limiting the weight of the packs to 70 pounds allows them to travel as normal luggage on a commercial airliner, if military airlift is not available. The Air force has a disaster response “force package” called SPEARR or Small Portable Expedi- tionary Aeromedical Rapid Response team that is deployable within two hours and “sling-loadable”. This means that the equipment can be transported from different locations via a sling from a helicopter or pulled by a standard pickup truck or airlifted by helicopter. The Air Force is testing Mobile Digital Imaging System shelters to be used during emergency field procedures such as orthopedic or vascular surgery to enable surgeons to locate critical injuries. Each shel- ter includes a lightweight x-ray device that can do a 360 degree scan of the patient, imaging workstations including monitors, plus the equipment needed to transmit and receive digital images via the internet using private military communication channels. The Air Force uses Portable Remote Diagnostic Information and Telemedicine Systems (PORDITS) to bring commercially produced laptop-based program to clinics in the Pacific. With an ordinary laptop and some plug-ins, PORDITS brings advanced diagnostic ability to forward locations. The system allows studies to be digitized so that they can be emailed to home-based specialists for further consultations. PORDITS provides for ultrasound spirometry, electrocardiogram, blood oxygen saturation measurement, and digital photography. Previously, if a patient suffered a blunt trauma to the abdomen while deployed to an austere location, it would take hours for the doctor to diagnose internal bleeding. Now that determination can be made in minutes using PORDITS ultrasound capability. 152 Federal Activities in Telemedicine, Telehealth, and Health Technology

Air Force Medical Service AFMS cares for over 2.6 million Air Force beneficiaries with more than 40,000 healthcare professionals serving 76 military clinics, hospitals, medical centers, and battlefront facilities.

Data Modeling and Analysis Office The Office of the Air Force Surgeon General Modernization Directorate established the Data Modeling and Analysis (DMA) Office to build and maintain centralized, web-based informatics tools to improve efficiencies. DMA and a partner built a balanced scorecard web site to provide monthly progress reports for each major command and medical treatment facilities. In addition, in-depth reports are published and are available via email to subscribers. The reports pull together information and provide data on chronic quality problems throughout the Air Force.

Web-based Tools to Help the Efficiency and Quality of Care Reports on schedules and patients are available through the Access Improvement Module. The system compares the patient’s needs and their demands for clinicians to use to identify where there are problems. To help managers in the system, the Business Plan Reporting Analysis Decision and Reconciliation System looks at the healthcare system in terms of productivity. The system determines targets according to demand and looks at future schedules for the physicians. The purpose is to determine whether the number of appointments is keeping up with the number of patients. The Complex Patient Management Tool looks at the number of patients in the system and the number of prescriptions they are taking to see what patients may need additional care in terms of disease management. The Service Delivery Assessment tool provides patient feedback on patient satisfaction obtained from telephone surveys with the results going to the leaders at all the military treatment facilities. The Air Force uses computer based post-deployment health assessments theater-wide. The assessments are part of the database used to track Airmen’s immunizations. All post deployment data is sent to a central database at Brooks City Base in Texas to identify an individual’s exposure to environmental, physical, and psychological stressors. The home station uses the information to reintegrate the individual back into the unit. The Air Force uses a web-based application to better understand and prioritize the quality of life needs facing service members and their families. The Air Force identifies quality of life services, understanding what these needs are and then develops services around those needs. The system has an advanced survey component that allows the staff to easily and quickly create, edit, and deploy customized surveys to the end user. The staff tracks the delivery of services, analyzes the effectiveness of these services, and assesses priorities based on ongoing field surveys. 153 Federal Activities in Telemedicine, Telehealth, and Health Technology

Bioterrorism and Disaster Response The Global Expeditionary Medical System (GEMS) is the foundation for an Air Force-wide integrated surveillance and medical command and control network. All the Air Force systems will be networked, detect and identify biological and chemical warfare agents, and then be incorporated into the provider patient data. The Air Force has established the Air Force Development Center for Operational Medicine in San Antonio Texas. The Center is the single source for Air Force satellites to conduct medical research, education, and training for all levels of disaster response, and helps DOD identify what resources are available by transitioning emerging technology from concept to implementation. The Air Force is working with other services and the private sector to create hand-held portable sensors to recognize and combat a potential epidemic within the first three hours of its introduction into the population.

Research The Air Force is doing research on materials and have invented a process called “Reactive Surface Treatment” to provide individual protection on garments from warfare agents. Multifunctional garments have been produced that are antibacterial, waterproof, and oil resistant. Use of the material is ideal for the military and first responders.

Wilford Hall Medical Center http://whmc.af.mil A major telemedicine effort at Wilford Hall Medical Center works with patients at hospitals in the four-state TriCare Southwest Region to include Texas, Oklahoma, Arkansas, and Louisiana. Wilford Hall Medical Center is the test site for the Defense Vision Information System (DVIS), an automated information system designed and ready for programming and implementation. DVIS will be integrated into the DOD Health Care system and become part of the Spectacle Request Transmission System and the Eye Injury Reporting System to track eye injuries. The physicians at Wilford Hall have developed a state-of-the-art patient tracking system called “Emergency Medicine Three (EM3). The system was designed by emergency physicians for emergency physicians with patient care being the top priority. Doctors, nurses and medical technicians gave direct input. The team then goes up the chain of command to see how to incorporate tracking elements not directly related to patient care. The system manages the emergency department patients throughout registration, triage, evaluation, treatment, disposition, and follow up. The program captures vitals, patient history, and nursing assessments, prints out physician charts, nursing worksheets and other forms on demand, assigns initial patient location, and retrieves information on appointments, demographics, laboratory and radiology results, as well as displays patient allergies and medications. The Medical Center now has a computerized inventory system supporting cardiology services deployed in the cardiac catheterization and electrophysiology laboratories of the hospital. The Wilford Hall Medical Center Critical Care Air Transport Team is testing technology to improve patient care in the air. They are looking at the capabilities of the medical heads-up display (MHUD) that is a stand-alone battery operated computer system with a band that fits over a person’s head. The band fits 154 Federal Activities in Telemedicine, Telehealth, and Health Technology

under the uniform cap and has a small transparent screen that covers one eye to enable eye-level monitoring capability for numerous patients. The MHUD technology uses military applications and brings this technology to the medical community. Nursing students at the Medical Center use the Noelle simulator. The system has an interactive learning program on CD-ROM with instructional material on anatomy and physiology, prenatial care, ante partum care, postpartum care, maternal resuscitation, and neonatal resuscitation. The system can be programmed to deal with high risk deliveries and can be used for basic and advanced cardiac life support training. The Wilford Hall Medical Center uses the Zeus MicroWrist Surgical System to provide a new degree of dexterity and precision. With this system, three compact robotic arms are clamped to the operating table to hold and position microsurgical instruments. While manipulating these instruments, the surgeon sits at an open portable console with unobstructed views of the patient and systems controls and communicates with the operating room staff. The optical portion of the technology allows 3D telementoring, telemonitoring, and telesurgical capability for control of the endoscope. The Medical Center has developed the “Rapid Identification and Registration Process for Trauma Patients”, and the “Pre-Operative Operation Risk Management Checkride” to help patient safety. The registration identification policy directs that all Code III trauma patients receive a special registration band and stamp plate when they arrive at the Wilford Hall emergency department. Two unique patient identifiers on the band are used to verify the patient against orders given prior to the patient’s official admission. The identifiers include a registration number and a name for the patient. An identifying registration band is created by emergency department personnel and placed on the patient’s leg. At the Prince Sultan Air Base in Saudi Arabia, the Air Force has teleradiology equipment linked to the Wilford Hall Medical Center. In addition, the Air Force has teleradiology demonstration projects at the David Grant Medical Center, Travis AFB in California, and has several other ongoing projects with several outlying medical facilities of the Army, Navy, Coast Guard and Department of Veterans Affairs. Wilford Hall has implemented radio frequency identification-based tracking storage and technology. The system uses RFID tags attached to supplies locked in an inventory cabinet with specific clinicians having permits to the software. The technology installed in the cardiac catheterization and electrophysiology laboratories, tracks stents, balloons, pacemakers, and other implantable devices.

Tinker Air Force Base http://www.tinker.af.mil The Air Force Materiel Command provided the 72nd Medical Group Optometry Clinic at Tinker Air Force Base in Oklahoma with eye technology called Optos 2000. The device is a low powered scanning laser ophthalmoscope and makes it possible to do an eye exam without dilating the eyes. By not dilating the eyes, officials project that the device will be able to save more than 72,000 hours each year in lost production and downtime. However, Optos will not entirely eliminate the need for dilations, since initial dilated eye exams are required as well as updates every three to four years. The Optos digitally scans the retina, the interior lining of the eyeball and creates an Optomap, which is a digitalized image of the retina. Once the digital image of the retina is uploaded, doctors and technicians are able to determine if there are retinal lesions and are able to spot early signs of glaucoma, macular degeneration, and retinal tears. 155 Federal Activities in Telemedicine, Telehealth, and Health Technology

Kessler Air Force Base The VA and the DOD Health Executive Council has approved a Joint Incentive Fund proposal for the Keesler Medical Center and the VA Gulf Coast Veterans Health Care System in Biloxi. The funds will be used at the joint cardiac care center at Kessler to upgrade the existing angiography suite and will serve as a dual cardiac catherization laboratory and peripheral angiography suite. The project will enable sharing between cardiology, radiology, and vascular surgery. The Air Force Base is doing distance learning over the internet and developing virtual classroom innovations. Kessler is using two free web conference tools provided by the Defense Information Systems Agency that offer two-way video, audio, and a chat box as well as the ability to provide visual aids to the students. The tool currently being used is the Net-Centric Enterprise Services E-CollabCenter along with a second tool called the NCES Defense Connect Online.

David Grant Medical Center http://www.travis.af.mil/units/dgmc/index.asp The Cardiovascular diagnostic Department at David Grant USAF Medical Center has acquired the iE33 cardiac ultrasound system from an international medical imaging company. The system has advanced diagnostic imaging capabilities with an intelligent system interface coupled with AFSO21, to provide streamlined ultrasound examinations for patients and clinicians at the Center. Mental health therapists and social workers at the center are currently using a virtual reality program to treat service members who suffer from post traumatic stress disorder after returning from combat. The VR software includes a motion inducing platform, headphones, a cued-smells generator, a mock M-16 with directional controls/game controller and a virtual reality visor. The system lets the individual re- experience troubling events under the supervision of a mental health expert while the individual is in the safety of a controlled setting in a hospital.

Next Generation Internet The Air Force Research Laboratory Information Directorate and SAIC of San Diego, California are developing virtual private networks in the Next Generation Internet (NGI). The research funded by DARPA under the NGI program, will establish NGI connectivity and develop next generation virtual private network technology to support several applications.

Other Telemedicine Activities • The Air Force’s Composite Occupational Health and Operational Risk Tracking (COHORT) initiative provides occupational and medical surveillance for the duration of service until retirement or separation. The system presents medical conditions, exposure data, control groups, and demographic databases to globally reduce disease and disability and works in near real-time. Eventually, the system will continuously 24/7 search for key sentinel events. • At Wright Patterson AFB, radiologists have adapted a commercial off-the-shelf (COTS) voice recognition software package to allow direct transcribing of radiology reports. A recent evaluation showed that this specialized system is saving approximately $1,500 per month per radiologist in transcription costs 156 Federal Activities in Telemedicine, Telehealth, and Health Technology

• The TRICARE Region 10 in Northern California is using a COTS software package to connect a virtual private network between David Grant Medical Center and several military medical facilities in Northern California for teledermatology service. • The Air Force has created a system called the Preventive Health Assessment Individual Medical Readiness Program (PIMR) to tell medics which troops need blood tests, evaluations, vaccines, provide real-time statistics in order to know how many troops are medically fit to deploy • The Air Force has a South West Asia Telemedicine Plan for inclusion into the overall SWA Medical Information Plan developed by the Air Force Theater Medical Informa- tion Program. The Air Force has an Air Transportable Hospital that flies weekly from the Ramstein Air Base Landstuhl Regional Medical Center to the field and transports the patients back to the hospital • The Air Force is using video conferencing, voice mentoring, mobile-high-bandwidth communications systems, and digital imaging to speed evacuations • The Air Force has bar coded information on drugs with standardized labels to allow each medication to be checked with a picture of each drug is on a computer screen • The Air Force is using the Suicide Event Surveillance System (SESS), a web-based information management application to provide secure, real-time data to all operation levels of the Air Force. The development of SESS provides a real-time centralized data repository for all suicides and non-fatal self-injurious events. E-mail notification is automatically sent from the input source to the Force Health Protection and Surveillance Branch • The Air Force uses Patient Support Pallets (PSP) to make it easier to turn any Air Force mobility aircraft into an aeromedical evacuation platform. PSPs contain specially packed medical equipment that can be installed into cargo and transport aircraft within minutes.

Defense Advanced Research Projects Agency

http://www.darpa.mil The Defense Advanced Research Projects Agency (DARPA) a separately organized agency within DOD, does advanced basic and applied research and development projects. Basically DARPA looks at high-risk, high-payoff technologies in the areas of Command and Control/Logistics, sensors, communications, land warfare, and weapons.

Combat Medical Informatics Program The Combat Medical Informatics (CMI) program a joint effort between government, industry, and academia integrates information technology to support military medical needs. The goal is to create, update, and transmit Battlezone Electronic Patient Records as early as possible in combat and non-combat situations. Workstations and ruggedized portable computers designed for field and fixed facilities help medical personnel provide electronic methods for recording and displaying patient medical information. 157 Federal Activities in Telemedicine, Telehealth, and Health Technology

Defense Science Office http://www.darpa.mil/dso DARPA’s Defense Science Office in their Biological Sciences Program is working on several programs.

Advanced Biomedical Technologies Program The ABMT program focused on several technologies, but the program has now moved from the Defense Science Office into the research and development community. The program was designed to create new devices to save soldiers previously lost in combat. The program succeeded in these research areas:

• The Personnel Status Monitor (PSM) is worn by soldiers to report vital signs and locations. Using the PSM data, medics quickly locate a wounded soldier and determine the severity of the injury. The program led to the commercial development of two other diagnostic technologies such as smart –t-shirts and hand-held portable ultrasound units that reconstruct images into full 3D renderings. Other DARPA funded technologies include direct digital x-ray systems, non-invasive sensors to measure blood gases, body chemistry, or the severity of burns, and provide for a direct digital pathology system. • Therapeutic technologies enable advances in robotics, miniaturization, and telemedicine to permit surgeons to perform telesurgery from a remote console • The Life Support for Trauma and Transport provides portable intensive care during evacuation. The LSTT provides a ventilator, IV fluid therapy infusion, a resuscitation system complete with monitoring and telemedicine capabilities • DARPA uses an integrated virtual reality training program for combat casualty care. Researchers developed VR technologies for both part task training and situational training. High performance part task training simulators allow medical personnel to rehearse sutur- ing, sinusoscopy, endoscopy, knee arthroscopy, catheter insertion, and vascular stent placement. Successful situational training projects include the Simulated Corpsman (SIMCOR), I-Port and VR multimedia training.

Biological Sciences Program Bio-Revolution DSO is working on advanced diagnostics, decontamination, and on medical therapies that are active against an entire spectrum of infectious agents. The Rapid Vaccine Assessment Program is creating an artificial human immune system on a chip consisting of human immune cells and micro scale immune structures. The program is working on new ways to test vaccines. Now DARPA is able to model the human immune system using a high throughput automated system. DARPA is working to shrink the time from first pathogens entrance to when DARPA can produce million of vaccines and therapeutics to help the infected in sixteen weeks or less. DARPA is developing new materials, processes and devices that are inspired by living systems. The agency is working to devise a machine that will come close to the brain’s ability to recognize visual patterns. The NeoVision 2 program is studying the mammalian visual pathway and the brain activity 158 Federal Activities in Telemedicine, Telehealth, and Health Technology

associated with sight and use state-of-the-art microchip designs in silicon-based devices. If successful, the technology will establish new architecture for image processing and artificial vision devices that may help restore vision after a severe eye injury. DSO is studying environmental stresses that address both the physiological and the psychological effects of the environment, how to advance in neuroscience, and looking at traumatic brain injuries caused by blasts. The idea is to scientifically characterize and understand how blasts cause neurological injury and the cumulative effects on the brain from repeated small blasts. A major effort is underway to maintain the soldier’s peak physical and cognitive performance once deployed despite extreme battlefield environmental stresses. Researchers are working to restore combat capabilities after severe injuries, and the goal is to fully restore the function of complex tissues, such as muscles, nerves, and skin after traumatic injury on the battlefield. DARPA is working on limb prostheses that are fully functional, neurologically controlled, and have normal sensory capabilities. The goal is to not only regain motor control, but also the ability to sense an artificial limbs position without looking at it and to actually feel precisely what the artificial limb is touching by relaying sensations through residual nerves. DARPA is planning clinical trials on an upper limb that not only functions and controlled by the brain, but also will be able to provide full sensory feedback to the patient. The Bio Magnetic Interfacing Concept is looking at ways to control biological activity at the cellular and ultimately the singular molecular level.

Bio-Materials The Bio-Molecular Motors Program is exploring micro-scale biological components to provide new capabilities for military relevant sensors and electronic devices and developing nanoscale magnets capable of sensing and signaling at the single molecule scale. The MOLDICE Program is developing platforms where biological channels interface directly with electronic devices to create digital converters.

Information Technology DARPA is working on embedded systems. These systems are special purpose computer systems contained in the device they help control, and enables advanced intelligent functionality for flight control, radar, and electronic countermeasures. Embedded computing is critical across a broad range of military applications, from handhelds, fielded systems and intelligent weapons systems to airborne information and command centers. DARPA is working on technologies for efficiently designing embedded systems for high performance flexible embedded processing and for recovering and maintaining investments in software. In the Polymorphic Computing Architecture program, DARPA is developing a class of flexible processors which can be reconfigured dynamically as required by the mission. Another project is using simple automated ventilators suitable for use by combat medics.

Microsystems DARPA is shrinking complex systems into chip-scale packages and integrating microelectronics, photonics and micro electromechanical systems (MEMS) into systems on a chip with new capabilities. The Navigation-Grade Integrated Micro Gyroscope program is developing tiny, low powered, rotation rate sensors capable of achieving performance commensurate with requirements for GPS denied naviga- 159 Federal Activities in Telemedicine, Telehealth, and Health Technology

tion of small platforms. The Data in the Optical Domain Network program has shown a path to an optical network that eliminates electrical to optical to electrical data conversion at each data router, thereby increasing the projected network data.

Predicting Health and Disease Program DSO is working on the Predicting Health Disease (PHD) project. In the civilian community if a person becomes ill, they are able to call in sick. This is not possible in military operations where missions depend on the ability to perform at peak performance. The PHD program will develop methods to assess whether an individual will develop an infectious disease, prior to the onset of disease symptoms to allow for early preventative treatments and infections control. The goal is to develop a field portable point-of- care health assessment system.

Defense Sciences Offices Transitional Section The Transitions section of the Defense Sciences Office has information on programs that have been completed, or transitioning from the Defense Sciences Office to the Services, other Government organizations, and to commercial industry.

Intelligence Advanced Research The Intelligence Advanced Research Projects Activity is a new corollary within DARPA and is in a temporary location at the University of Maryland. A permanent facility will be developed near the campus with high level security to support advanced intelligence research.

DARPA Small Business Innovation Program http://www.darpa.mil/sbir DARPA’s SBIR program funds projects involving sensors, materials research, molecular electronics, optoelectronics, and hypersonics technology. DARPA’s SBIR program has produced solid state laser systems that are compact, efficient, and reliable with a variety of applications. These applications encom- pass basic research and development, communications, fiber optic sensing, semiconductor processing, and medical procedures. One of several products developed using SBIR funding, is a small portable laser used primarily in eye surgery. The small laser is ¾ of a cubic foot in size and weighs 24 pounds replacing a product that was 24 cubic feet in size and weighed 220 pounds. The portability resulting from the decrease in size and weight increases the accessibility of healthcare to older less mobile patients and to patients in rural and third world locations. Sensant Corporation in San Leandro, California is working with DARPA on ultrasound medical imaging technology. The contract is titled “Virtual Ultrasound Transducer Control for Telemedicine Application of Flexible MEMS Arrays.” AFrame Digital LLC and partners was awarded a SBIR contract to deliver non-intrusive health monitoring for post battle wellness to the military forces. Virginia Commonwealth University’s Medical College of Virginia and iTelehealth Inc both work with AFrame Digital. 160 Federal Activities in Telemedicine, Telehealth, and Health Technology

DOD Defense Solutions http://www.defensesolutions.gov Defense Solutions is a new idea portal where companies, entrepreneurs, and research organizations can offer potential solutions to DOD. The portal and the team behind are there to encourage companies that have never considered doing business with DOD to participate in the program. The team is there to provide direct communication with companies when an idea is submitted and to work all the way through with the company to get results.

DOD Science and Technology Dual Use Program http://www.acq.osd.mil/organization.html The Department of Defense Science and Technology Dual Use Program funds shared projects between DOD and industry to introduce commercial technology to the military. Of the 355 different non-federal partners participating in the program, 130 are commercial firms with interests in medical and bioengineering technology. The Telemedicine and Advanced Technologies Program works on using sensors with medicine, and has more than $800 million available in funding for 300 projects. The program has worked on both military and commercial applications since the program began and industry benefits by participating in these shared projects. The Research Triangle Institute funded under a Dual Use Science and Technology Award and partly supported by the Army, has developed the Simulation Technologies for Advanced Trauma Care (STAT- Care). This research work developed a trauma patient simulator that is an interactive VR based simulator to offer realistic practice to the trauma care provider. The system presents the user with a 3D visual and aural scenario in which a trauma incident has occurred. The user may freely navigate within the scene, view the scene and patient from any position and angle, and interact with the patient and scene objects.

Armed Forces Institute of Pathology http://www.afip.org The Armed Forces Institute of Pathology (AFIP) a tri-service agency of the Department of Defense provides consultations on cases, education, and does research in basic science, environmental pathology and toxicology, geographic and infectious disease pathology, oncology, molecular diagnostics, and forensic science. AFIP serves as the central diagnostic source for military and civilian anatomic pathology and applies emerging technologies in genomics, proteomics, informatics, and telepathology. The Center for Advanced Pathology supports telemedicine to work with AFIP on developing telecommunications technology to improve the speed of services and educational opportunities for personnel. The Department in cooperation with pathologists from five departments launched a pilot study to evaluate the feasibility of incorporating digital images into AFIP consultation reports. Since the study was initiated, many reports have been completed and the department has concluded that routine cases, quality assurance cases, and cases which are in complete agreement with the contributor, are not truly improved by the use of digital images. However, the digital images are particularly useful to demonstrate diagnostic features and are useful in answering critical diagnostic questions on difficult cases. AFIP launched “AskAFIP™ version 2.0 so that any pathologist or clinician will have computer 161 Federal Activities in Telemedicine, Telehealth, and Health Technology

access to a wide range of content. The system provides information on cases from the AFIP Central Re- pository complete with radiographic imagery, articles published by the staff, and access to AFIP Tumor Pathology published by the American Registry of Pathology. Users can review cases from the database, select an organ system, review the patient’s history, see pertinent radiological findings, and look at virtual slides. The system provides information to everyone from board-certified specialists to medical students in many related fields. AFIP is working with the Telepathology Department to upgrade the histology units as some of the overseas Army programs are sub-optimal for telediagnosis. Researchers and staff from AFIP are working with WRAMC to support research on wound control. This has resulted in a partnership between the Combat Wound initiative Program and AFIP’s Complex Wound Biospecimen Network Program. The biorepository will be maintained by AFIP’s Division of wound biology and Translational Research. The division is establishing a “Combat Wound Microbial Culture Collection” and a “Combat Wound Genomic Repository.” Researchers will be able to study combat related infections and genetic characterization of microbial agents isolated from the wounds. Extracted metal fragments, foreign bodies, and biospecimens are being submitted to AFIP’s Divi- sion of Biophysical Toxicology for biotoxicity studies. Metal fragments tissues and related wound biospecimens are analyzed and go into the “Depleted uranium and Embedded Metal Fragments Registries.” AFIP is located physically on the Walter Reed Campus and is scheduled to close when the WRAMC campus closes with AFIP services transferring to other parts of DOD or be contracted out to the civilian community. As of January 2009, the Defense Authorization Act requires the Joint Pathology Center (JPC) to function as the reference center in pathology for the Federal government. There are uncertainties in establishing JPC and it is not absolutely certain that JPC will be established in the Defense Department as JPC could be established in another Federal agency. A joint Pathology Center Working Group will determine the location of the Center and it may be located within AFIP.

Uniformed Services University of the Health Services http://www.usuhs.mil USUHS receives research funding from the Army, Navy, and Air Force along with funding from NIH and the National Science Foundation. Approximately $25 million to $30 million in grants is funded with the Department of Defense and NIH. The university has basic science departments and three multidisciplinary programs. USUHS is integrating new informatics technologies and competencies into training for healthcare professionals.

Virtual Reality The Wide Area Virtual Environment (WAVE) an 8,000 square foot full scale immersive virtual reality area enables teams of student to use state-of-the-art technologies to conduct clinical and surgical skills training. Students take part in mass casualty drills, biochemical attacks, and other medical training scenarios by using simulators. Wave uses three vertical screens to display the environment. Observers standing in the enclosed space have the illusion of being immersed in a 3D environment. Stereoscopic images are displayed using projectors with polarized filters with users wearing lightweight polarized glasses to view the scene in stereo. 162 Federal Activities in Telemedicine, Telehealth, and Health Technology

Department of Biomedical Informatics http://cim.usuhs.mil USUHS has established a Department of Biomedical Informatics with three areas of specialization including bioinformatics, medical informatics, and education. The department serves as a clearinghouse for USU informatics applications and is a testing facility for informatics research. The department works closely with NLM’s Lister Hill National Center for Biomedical Communication and is working on an advanced three dimensional visible project with the University of California, San Diego. The Department provides current basic and advanced information about genetics to DOD primary care providers, specialist physicians, and other health care providers, USUHS medical and graduate students, and researchers.

Department of Radiology and Medical Informatics The Department of Radiology and Medical Informatics has developed a database driven online Image Library and Teaching File Program called MedPix. Health professionals now have a cataloged and searchable database of annotated medical images. This service serves as a worldwide archiving and retrieval source for imaging studies involved in the diagnosis of over 60 parasitic and infectious neo- plastic and miscellaneous diseases affecting over two billion people in tropical and subtropical regions of the globe. The system provides more than 19 percent of all continuing medical education credit hours at USU. In combination with an archive of past uploaded images, a “Clinical Case of the Week” features two to three questions for a review of medical literature. Physicians and students are also able to take tests and receive scores using an automated system. USUHS is developing digital tools that will make it easier to acquire, view, and manipulate three- dimensional images such as mammograms quickly and efficiently. The National Naval Medical Center, GE Global Research and the University of South Florida are collaborating on projects.

Centers Medical Simulation Center and Patient Simulation Laboratory http://simcen.usuhs.edu USUHS established the National Capital Area Medical Simulation Center and Patient Simulation Laboratory located at the Walter Reed Army Medical Center. The Center brings together virtual reality technology, mannequins, and actor patients. Nurse anesthetists, anesthesiologists and surgeons work on digitally enhanced mannequins that can be programmed with more than 20 patient profiles and over 35 customizable events to simulate medical conditions and emergencies. Students wear special glasses while operating surgical instruments and are able to look into a three dimensional screen and cut or sew tissue displayed on the screen. The simulation laboratory consists of an operating room with two components, the control room and the operating room. The OR has been constructed to replicate the dimensions of a military DEPMED field deployable operating room or as an emergency room or intensive care unit and is equipped with oxygen, nitrogen, and vacuum lines that are accessible through wall mounted outlets. In addition, the operating room has two ceiling mounted cameras and microphones to record exercises for later analysis remotely steered from the control room. The operating room has two patient simulators, the Laerdal 163 Federal Activities in Telemedicine, Telehealth, and Health Technology

SimMan Universal and the MedSim Eagle Patient Simulator, a bronchoscopy simulator, and a MedSim UltraSim ultrasound training simulator. The Surgical Simulation Laboratory develops simulators in the Virtual Reality room. The VR room has six dual-processor Intel workstations for software development including a hand immersive workstation. The VR room is equipped with its own dedicated LAN that can be isolated from the main network for bandwidth intensive experiments. In addition to copper, fiber optic links the VR room with the OR and the rest of the simulation center and provides a link between the surgical suite at Walter Reed Army Medical Center and the USUHS Surgical Simulation Center. A fiber network links with the university’s Internet2 for experiments involving more remote locations. The VR room houses a number of the laboratory’s medical simulators. They include the vascular anastomosis, pericardiocentesis, diagnostic peritoneal lavage, and laparoscopic simulators.

Casualty Care Research Center The Casualty Care Research Center has deployed telehealth technology to seven countries with a Telegenetics web site serving many diverse locations. University students, medical personnel assigned to Walter Reed Medical Center, the National Naval Medical Center, and the Malcolm Grow U.S Air Force Hospital at Andrews Air Force Base, train at the center.

Center for Disaster and Humanitarian Assistance for Medicine http://www.cdham.org The Center for Disaster and Humanitarian Assistance for Medicine located in the Department of Military and Emergency Medicine has information on chemical and biological warfare and terrorism. The Center serves as a clearinghouse for information related to all areas of disaster medicine and humanitarian assistance, and information on telemedicine and medical informatics as it relates to austere environments.

Center for Preventive Medicine and Public Health The Center develops databases, prepares innovative curriculum, and evaluates processes and outcomes in clinical practices.

Center for the Study of Traumatic Stress The Center provides multidisciplinary expertise in disaster psychiatry, military medicine, psychiatry, neuroscience, and workplace preparedness.

Distance Learning Program USUHS conducts a nursing course as part of the Defense Department Distance Learning Program by using video conferencing. The distance learning program is designed specifically for VA nurses who have attained advanced practitioner qualifications and advanced degrees. The USUHS training qualifies them as adult nurse practitioners. The students with access to the Learning Resource Center have access to more than 600 health and medical journals electronically. The USUHS Graduate School of Nursing is running a pilot distance learning project for military service personnel stationed abroad or abroad military ships. 164 Federal Activities in Telemedicine, Telehealth, and Health Technology

New Research USUHS researchers are studying how lasers affect corneas to be able to identify new therapies for battlefield laser eye injuries. Up until now, research has focused mainly on damage to the retina, but the cornea, the most exposed part of the eye, is most susceptible to irreversible laser injuries.

Graduate School of Nursing http://cim.usuhs.mil/gsn Perioperative Clinical Nurse Specialist Program The PCNS program and the U.S. Pharmacopeia are collaborating on a medication error reporting system. The PCNS students worked with Pharmacopeia on MEDMARX, the world’s largest medication error reporting system. The classes have focused on pediatric medication errors across the perioperative continuum.

165 Federal Activities in Telemedicine, Telehealth, and Health Technology

Department of Veterans Affairs

http://www.va.gov The Recovery Act or Stimulus funding will provide one billion for the Veterans Health Administra- tion (VHA) to use to improve medical facilities, purchase needed IT systems, and to improve the medical center facilities. The VA plans to pursue needed information technology initiatives for improved benefits and services. The VHA provides hospital care, nursing care, home care, and outpatient medical and dental care to eligible veterans. The VHS employs over 2000,000 full-time equivalent employees, including more than 14,500 physicians and over 60,000 nurses and nursing assistants. The system has 1300 care facilities, including 153 medical centers serving six million veterans many of which have chronic diseases, 755 community-based outpatient clinics, 232 Vet Centers, 931 ambulatory care and community-based outpatient clinics with plans to open 44 new clinics in 21 states, 232 counseling centers, 134 nursing homes, 43 domiciliary facilities, and 108 comprehensive home-based care programs. The VA provides acute care, mental health care, prosthetics, rehabilitative care, dental care, long term care, and readjustment counseling. In 2009, the VA treated 333,275 Operation Iraqi Freedom and Operation Enduring Freedom veterans. The Department is establishing a genetic database to collect 100,000 DNA samples from veterans, with the database eventually containing the DNA for millions of patients. The agency has a panel of geneticists to oversee issues such as ethics, the risks to veterans, and privacy. The VHA’s specific plans for long term care are to:

• Focus on TBI and polytrauma but also to research blast-force related brain injuries, burn injuries, and how to deal with chronic pain • Achieve an integrated care management system to incorporate all of the patient’s clinical care needs • Achieve greater consistency in quality of care provided in all settings • Achieve greater consistency in assessing patients for extended care and in managing care including post institutional care • Continue to emphasize VHA research and educational initiatives to improve delivery of services and outcomes for VA’s elderly veteran patients • Continue to develop new models of care for diseases and conditions that are prevalent among elderly veterans

The VA Medical Centers in their national Medical Preparedness Centers conduct bio-medical research and develop responses to terrorism. The legislation authorized $100 million over five years to fund the new centers to provide healthcare during major disasters and medical emergencies.

Medical Centers Using Telemedicine • Medical Center in Memphis Tennessee uses telemedicine technologies to monitor blood pressure, pulse, blood sugar in the home with the results transmitted via a modem to a physician. Telemedicine is used in mental health to help veterans with spinal cord injuries. The Center has a full picture archiving computerized system in radiology. A project will help caregivers manage both patient behaviors and their own stress. 166 Federal Activities in Telemedicine, Telehealth, and Health Technology

• The VA Palo Alto Health Care System uses telemedicine to focus on diabetes, chronic heart failure, and COPD. Veterans are able to send their blood sugar results, weight, and blood pressure readings to a secure website monitored by nurses. The goal is to use more technology to help with mental issue and spinal cord injuries. • The Black Hills Health Care System uses telemedicine in cardiology, endocrinology, infectious diseases, orthopedics, and plastic surgery. Telemedicine is used with diabetic patients to determine if the patient has diabetic retinopathy, for dermatology, and to treat mental cases • Erie Medical Center uses telemedicine to help in behavioral health in outpatient clinics and to follow-up with veterans involved in sleep studies from the Pittsburgh VA Healthcare System • The Gainesville Medical Center has caregivers taking part in a Transition Assistance Program to provide skills training, education and supportive problem solving using videophone technology • The VA Desert Pacific Network and the Sierra Nevada Healthcare System help caregivers taking care of people with TBI use computer-based telehealth, including Web, telephone and videoconferencing • The Atlanta VA Medical Center uses computer-based technology to help caregivers in remote areas that cannot leave a patient alone

Information Technology Veterans Benefits Administration http://www1.va.gov/health The 2009 stimulus package provides $50 million to go to the Veterans Benefits Administration for information technology. The VBA provides benefits information and has a number of clinical programs and initiatives to deal with Agent Orange, Gulf War illnesses, HIV/AIDS, nursing, patient safety PTSD, rehabilitation, cancer, pharmacy benefits, and geriatrics and extended care. President Obama has announced that the VA and DOD are collaborating on developing a joint virtual lifetime electronic record to include administrative and medical information collected during and after an individual’s military service. However, VHA and DOD share more patients with private sector providers than they do with each other.

Plans for Strengthening Security Protections VHA is taking specific actions to prevent security breaches such as:

• Implementing a department-wide encryption solution to encrypt data sent across networks. A workgroup has been established to identify solutions that meet business needs and are transparent to the end user • Monitoring compliance reviews of security and privacy program assessments to make certain that security is in compliance with VA and VHA security and privacy polices • Increasing the use of secure, web-based solutions for e-mail, scheduling and other administrative needs. VHA is implementing Outlook Web Access across VA facilities 167 Federal Activities in Telemedicine, Telehealth, and Health Technology

• Requiring that all portable media and laptops have the capability to encrypt all sensitive data • Updating VA and VHA security policies to address changes in technologies in the current IT environment

The Department of Veterans Affairs has reorganized IT throughout the agency. The reorganization places the IT budget along with IT professionals directly under the Assistant Secretary, Information, and Technology. IT workers involved in system development will remain under their respective administra- tions and staff offices. Over the past five years, the Department has spent about $1 billion each year supporting IT programs and expects IT expenditures to continue to increase over the next five years. Presently, there are 300 IT projects. In 2009, the VA temporarily halted 45 information technology projects that were either behind schedule over budget. The projects will be reviewed and then it will be determined whether these projects should be continued. The VA IT activities include:

• The VA is working with the Space and Naval Warfare Systems Command to develop an automated system to process claims. The system is due to be tested in 2010 and to be implemented in 2012 • Standardization activities to support VA/DOD sharing to eliminate redundancies in coding and to promote software and data use • Developing the Scheduling Replacement Project to improve access, decrease wait times for appointments, and increase provider availability. The national rollout will go to all VA sites in FY 2011 • The Laboratory System Reengineering will provide the VA with a modernized Laboratory Information Management System. In FY 2009, the system underwent independent verifi- cation and validation, plus field tests. The FY 2009 funding was used to acquire 20% of the equipment. National deployment will begin in FY 2010 and will be phased in over five years • The pharmacy suite of applications is undergoing modernization and pharmacy software modules will be replaced with new technology through reengineering, new development, and the purchase of commercial products. Plans are to deploy enhanced order checks in FY 2009, to improve patient safety standards • Activation of new VA facilities will bring new requirements for IT and assets. Some of the needs will be for desktop computers, mobile devices, laptops, etc. The VA plans includes 51 new community-based outpatient clinics.

The Austin Information Technology Center is a federal data center within the Department of Veter- ans Affairs to provide a full complement of cost-effective IT services to the VA and other federal agency customers. ATIC is participating in the VA’s health information modernization effort HealtheVet. The next generation HealtheVet is scheduled to provide clinical decision support tools so that clinicians can access and compute healthcare information regardless of where the veteran receives care. The modernization of VistA into the HealtheVet environment is being structured into blocks, with completion targeted for 2018. 168 Federal Activities in Telemedicine, Telehealth, and Health Technology

Contracting Healthcare Services with VA There are two principal avenues that the VA uses to contract for healthcare services and this includes contracting with conventional commercial providers and contracting through academic affiliates. All VA healthcare resource contracts are reviewed through the Office of General Counsel, VHA’s Patient Care Services, VHA’s Office of Academic Affiliations, and VHS’s Procurement and Logistics Office. The initiative established to manage the services the VA purchases is called Project HERO. This is a vehicle to purchase non VA services and provide specialty services that are not always available in the VA. Project HERO is in year two of a proposed five year contracting pilot to increase the quality and to decrease the cost for purchased (fee) care.

VHA Databases The databases include:

• My e-benefits is a web site that serves as a single customizable inclusive source for the wounded, ill, and injured to obtain information on benefits and support programs • The Veterans Health Information Systems and Technology Architecture or VistA incorporates EMR and CPOE along with data from information systems to obtain data from the pharmacies, laboratories and radiology facilities. The system treats four million veterans a year at 128 sites with EMR providing point of care data and alerts to physicians. The doctors input the information and the system tells the doctor once the transcript is ready. The IHS EHR system (RPMS) is based on the VA’s EHR system so the IHS has adopted VistA Imaging. The CPRS is the workhorse of VistA and provides real time order checking alert clinicians, provide reminders, provide remote data view, and e-prescribing. VistA imaging incorporates medical images into one complete patient record • My HealtheVet is a web-based application linking VA benefits and resources, the veteran’s Personal Health Journal, and has online prescription refill capabilities Participating veterans are given copies of key portions of their electronic health records, with the records stored in a secure environment called an eVAult. The eVAult is personalized with links to useful explanatory material to help the veterans understand what is in their record and what they can do to improve their health condition. The veteran owns the personal record and has complete control over who can view or update it. The system provides the latest news from the VHA, and a health calculator. In the future, the data will be stored in a veteran-centric format replacing the current facility centric system. Veterans will be able to view appointments and to allow family members and non-VA healthcare providers to see the information • The Federal Health Information Exchange/Bidirectional Health Information facilitates secure electronic patient medical information to go electronically between government health organizations • The Health Data Repository has select clinical data for veterans care used to create a longitudinal picture of the veteran’s health record. The Clinical and Health Data Repository works to provide interoperability for the DOD Clinical Data Repository with VA’s HDR. 169 Federal Activities in Telemedicine, Telehealth, and Health Technology

Care for the Wounded, Ill, and Injured VA and DOD have established the Federal Recovery Coordinator Program (FRCP) to identify and integrate the care and services for the seriously wounded, ill, and injured service members, veterans and families. The program is developing the National Resource Directory along with other Federal agencies to produce a family handbook. In addition, a Federal Individual Recovery Plan provides individual clinical and non-clinical plans for recovery purposes.

Rural Health Initiatives The VA provides competitive funding to help veterans in rural and highly rural areas and the VA has created an Office of Rural Health along with a Rural Health National Advisory Committee. The committee was formed to advise the senior leaders of the Department of Veterans Affairs on healthcare issues of concern to veterans in rural areas. The members come from the federal, state, and local sectors, academia, and from veterans service organizations. The Rural Health Initiatives that have been implemented:

• Expanded Care Coordination/Home Telehealth Programs to support veterans with PTSD and substance abuse problems that can be managed at home • Expanded the VA readjustment counseling program with telehealth • Implemented a national teleretinal imaging program with 50% in rural areas • Expanded mental health services at all CBOCs • Working with HHS and other entities such as NRHA • Have VA patients in 30 states using telehealth devices

The VA has opened Veterans Rural Health Resource Centers to serve as satellite offices for the Office of Rural Health. Each center will identify disparities in healthcare for rural veterans and formulate practices of program to help deliver better care. The VA is helping regional healthcare systems improve services in rural areas. Funds are being used to increase the number of mobile clinics, establish new outpatient clinics, expand fee-based care, explore collaborations with federal and community partners, accelerate the of telemedicine and fund innovative pilot programs.

Patient Safety and Health Quality The Department realizes patient safety is not a VA-specific issue, and joined with other healthcare organizations to understand the issues, to act on patient safety, and to work on a cross section of issues. The National Patient Safety Partnership, a public-private consortium of organizations with a shared interest and commitment to patient safety improvement was formed. The federal agencies involved include the Department of Defense (Health Affairs), National Institute for Occupational Safety and Health, FDA, Agency for Healthcare Quality and Research, and the Center for Medicare and Medicaid Services. The Veterans Health Administration created the VHA Expert Advisory Panel on Patient Safety, which led to the National Center for Patient Safety (http://www.patientsafety.gov). The Center reports directly to the VA Under Secretary for Health to help integrate patient safety efforts. The task is to devise 170 Federal Activities in Telemedicine, Telehealth, and Health Technology

systems that will fix the weaknesses in the systems that affect patient safety. In collaboration with NASA, the Department has a medical reporting system called the Patient Safety Reporting System (PSRS) (http://psrs.arc.nasa.gov) The PSRS is modeled after NASA’s Avia- tion Safety Reporting System (ASRS). The system has served the aviation community for 24 years and is available to all participants in the ASRS who wish to report safety incidents and situations. The PSRS improves patient safety through voluntary participation, confidential reporting, and non-punitive provisions for VA employees who chose to participate. VHA has programs to improve the quality of care such as:

• An internal clinical peer review program in each hospital • An External peer Review Program which extracts data from patient care records in VHAs clinical systems and compares the information with evidence-based performance criteria • A National surgical Quality Improvement Program which makes risk adjusted comparisons of surgical outcomes to identify surgical units with unexpectedly high or low rates of morbidity or mortality • An Inpatient Evaluation Center designed to improve outcomes in the acute care hospital setting by examining data from EHRs • A set of programs in the Quality Enhancement Research Initiative that aims to put clinical research findings and evidence-based recommendations into clinical practice • An Evidence-based Synthesis Program systematically reviews published research on medical issues of particular importance to VHSs user population

Bar Code Medication Administration System The BCMA system helps patients receive the correct medication in the correct dose at the correct time. In addition, the system provides real-time access to ordering medications at the patient’s bedside. The system alerts the nurse when the software detects the wrong patient, medicine at the wrong time, giving the wrong medication dosage, if there is no active medication order, if allergies may be a problem, and if possible adverse reactions may happen. These alerts require the nurse to review and correct the reason for the alert before actually administering the drug to the patient. Order changes are communi- cated instantaneously to the nurse administering medications eliminating the dependence on verbal or handwritten communication of order changes. The VHA provides audible prescription reading devices to more than 33,000 blind veterans, and uses the ScripTalk Audible Prescription System which uses Radio Frequency Identification (RFID) technology. To use the device, the patient positions the battery powered hand-held RFID reader to within a few inches of the specially printed label that has an embedded microchip and antenna. After pressing the play button, a synthesized voice gives the patient’s name, drug name, instructions for use, special warn- ings, beyond use date, prescribers name, pharmacy phone number, and prescription number. A special printer in the pharmacy produces readable information and encodes the RFID microchip on the self adhesive label. 171 Federal Activities in Telemedicine, Telehealth, and Health Technology

Mobile Pharmacies The VA has deployed mobile pharmacies to help provide medicine when patients are unable to fill their prescriptions, during times of major disasters and other emergencies. Each mobile pharmacy is housed in a 40 foot long solid steel trailer built to withstand winds in a Category 3 storm. The units include a satellite connection with the VA’s Consolidated Mail Outpatient Pharmacy system that can process 1,000 prescriptions hourly.

Telehealth Chronic Illness Care The VHA has developed a national home telehealth information technology infrastructure to take care of veterans especially those veterans needing chronic care. The present model for effective chronic illness care focuses on collaborative interactions between an informed activated patient and a proactive practice team, but the use of technology is essential to support these interactions. The Program uses home telehealth and disease management techniques plus health IT. The program treats patients with single and multiple conditions and patients with diabetes, CHF, hypertension, PTSD, COPD, and depression. The VHA uses informatics support to treat depression and schizophrenia and to develop support for other chronic illnesses. The system is designed to work with the VA’s Computerized Patient Record System and includes other features that are specific to caring for chronic illnesses. When treating patients at home, devices such as messaging, monitoring, and measuring devices are used along with videophones, and personal computers to send information on patients such as vital signs, disease management data, and e-health information to the National VHA Care Coordination Infrastruc- ture where it can go via the Internet or the Intranet and then to VistA and to hospitals.

Mental Health Telemental health has grown with over 16,000 patients per year receiving care. Outreach telemental health technologies are available at 74 VA medical Centers and Health Care Systems. These facilities use telemental services to augment services to 120 Community Based Outpatient Clinics with expansion an- ticipated to increase to 300 community-based outpatient clinics, hospital sites, and Vet Center programs. Fourteen telemental programs reach veterans homes and homeless shelters, via videophones and remote health monitoring devices. Geriatric programs are being integrated into mental health services. Research is being done in community-based settings to treat combat related post-traumatic psycho- pathology and similar adjustment problems. Some of the approaches under consideration are novel phar- macological, psychosocial and combination treatments as well as the use of technologies such as telehealth, and virtual reality therapy. The VHA has a 21 site Polytrauma Telehealth Network to connect Level I and Level II Polytrauma Rehabilitation Centers across a high-speed network to allow for real-time education and clinical consultations. Each of the VA’s 21 regional healthcare networks is establishing Polytrauma support clinic teams with psychologists and social workers to improve case management for veterans with TBI. The VA is opening new vet centers during the next few years. Fifteen of the centers are already operational and the five others are seeing patients in temporary facilities. The community-based Vet 172 Federal Activities in Telemedicine, Telehealth, and Health Technology

Centers are a key component of the VA’s mental health program. Nearly one-third of U.S. soldiers from Iraq and Afghanistan have returned with at least one mental health problem such as PTSD. To help provide resources, the VA established the National Center for Post Traumatic Stress Disorder at (www.ncptsd.va.gov/ncmain/veterans.) The site has up-to-date information to help veterans and their families cope with deployment, trauma, treatment, and provide information on the mental health impact resulting from the wars in Afghanistan. The VA has opened a call center to reach out. About 300,000 out of 800,000 who have separated and have come to the VA for healthcare, have touched the system one way or another. When they do, the veterans are now screened for PTSD and TBI and asked about suicidal tendencies. As part of the program, the center is reaching out to 17,000 veterans who potentially could benefit from case management but may not have access to it. A study is being conducted on telemedicine technologies that can be used to treat veterans with PTSD. Approximately 180 male veterans with PTSD and anger related difficulties were recruited from 3 Hawaiian Island clinical sites by VA primary care staff and the VET Center staff located on the corresponding neighbor island. The study uses telemedicine to help veterans have access to mental health services by conducting an Anger Management Therapy group treatment using VTC. The veterans using VTC will be compared to the treatment that veterans will receive with traditional in-person treatments. The Substance Abuse and Mental Health Services Administration within HHS is working with the VA, DOD, and veteran’s service organizations to understand needs, to better identify mental issues, and to assist veterans and their families. SAMHSA provides information to help veterans and their families find the best resources to help cope with substance abuse services and trauma. The VA has funded the “Neurons to Networks Center for Rehabilitation Research” at the Houston VA Medical Center. The new center will focus on improving the ability to diagnose veterans with mild to moderate TBI. The Center will develop and evaluate treatments involving virtual reality and neurobio- feedback. Since it is sometimes difficult to diagnose TBI, the VA is implementing a system-wide screening for TBI developed by a multidisciplinary team consisting of the VHA, DOD. The team asks four initial questions and if the answers indicate TBI, then further in-depth questions are asked and additional tests may be given to make a diagnosis and develop a treatment plan. Research continues on blast related injuries, The Defense and Veterans Brain Injury Center along with the private sector are collaborating on research and working together on clinical care. To accomplish these goals, conference calls are conducted monthly and two meetings are held every year.

Internet2 The VA joined Internet2 as an affiliate member and is connected to the nationwide network. Now it will be possible to deliver next generation medical services, provide for faster delivery of services, extend the reach for information, and decrease costs for service. The medical services provided include high resolution imaging, teleprescence, telepathology, and mental health counseling.

Research The VA supports medical research to nearly 2,900 high priority research projects in areas critical to healthcare needs such as Gulf war illness, diabetes, heart disease, mental illness, Parkinson’s disease, spinal cord injuries, prostate cancer, depression, environmental hazards, and women’s health care concerns. 173 Federal Activities in Telemedicine, Telehealth, and Health Technology

Some of the current research projects include:

• Traumatic Brain Injuries—a study will be done to look at combining state-of-the-art imaging techniques with comprehensive neuropsychological assessments to fully characterize patients with TBI as compared to other types of brain damage. Developing adult stem cell technology to protect and reverse effect of brain trauma, studying nerve damage repair after brain injuries, studying the impact of rehabilitation strategies on the brain after TBI pain management, studying the effects of concurrent PTSD on TBI outcomes, Looking at magnetic brain stimulation to improve rehabilitation, and better ways identify TBI • PTSD & TBI—studies are looking at neurophysiology, imaging, treatments, the comparison of virtual reality graded exposure therapy with cognitive behavioral group therapy, developing models of care including telemedicine and collaborative care approaches, studying biomarkers, developing a genetic database, and new drug development • Spinal Cord Injuries—researchers are testing micro-stimulators to recreate breathing and coughing patterns to help avoid respiratory complications. They are also developing systems that deliver low-level, computer-controlled electric current to the muscles, which may help all individuals with incomplete SCI to once again walk. They are also working on implantable electronic devices to improve the treatment of pressure ulcers • Prosthesis research—funding has been provided for two new Prosthetics Rehabilitation Engineering and Platform Technology Centers to develop computerized state-of-the-art prosthetic limbs using the latest advances in cutting edge technology, and using microelectronics and microchips in orthopedic surgery, tissue engineering, and nanotechnology. Researchers are looking at a Neuromotor Prosthesis to see if it would be possible to operate an artificial hand, robotic arm, or computer by using only thoughts. The technology being studied uses an electrode that picks up brain signals and sends them to a computer for decoding. The brain signals are translated into commands to power electronic or robotic devices including prosthetics. The Advanced Platform Technology Center at the Cleve- land VA Medical Center is focusing on sensory and implanted control of prosthetic limbs along with accelerated wound healing. The VA is collaborating with Brown University and MIT to develop a bio-hybrid limb that combines regenerated tissue, lengthened bone, and implanted electronic sensors to enable amputees to use their own brain signals to better control their artificial limbs. The VA is also partnering with DOD to improve prosthetic designs, define standards of function, and conduct outcome studies. The VA has developed high performance prosthetic devices, such as a bionic ankle that propels users forward

Other Research Efforts • The VA is involved in a research project to harness the power of natural language processing (NLP) to obtain more value out of electronic records. The project called the “Consor- tium for Healthcare Informatics Research” is working to change text in electronic medical records such as the doctor’s notes into structured data • Expanding the use of 3D imaging software to give physicians a virtual roadmap of a patient’s anatomy. The VA Palo alto Health Care system and Stanford University School of Medicine are working to expand the use of this technology 174 Federal Activities in Telemedicine, Telehealth, and Health Technology

• Researchers are working on ways that the “Veterans Informatics, Information, and Com- puting Infrastructure” (VINCI) project will be able to obtain electronic medical records from VA sites nationwide and put the records into one secure centralized data repository • Researching an electronic system to enable veterans with MS to report their symptoms and vital signs as well as receive education regarding MS on a daily basis • Studying genetic information so that computer systems will be able to manage genetic data and identify genetic predispositions. • Identifying the most effective treatment methods to reduce the incidence of diabetes among veterans and make advances pinpointing genes for diabetes and obesity • Doing research on artificial retinas and working with Joslin Diabetes Center to implement a national teleretinal imaging program to assess diabetic veterans for eye disease. The program will goes to 92 sites • Studying the mechanism for respiratory distress syndrome • Studying the chemoprevention of prostate cancer, basal and squamous cell skin cancer • Studying how to prevent kidney disease in diabetics by using various drug combinations • Ongoing research on telemedicine and collaborative care • Studying the normal age related changes in physical and mental functions, aging syndromes, co-morbid chronic illnesses, end of life issues, vaccines for Alzheimer’s, and peptide-based agents in various cancers

Research Collaborations with DOD • DOD and the VA are developing an interagency interoperability plan to improve patient safety and care. • The VA participated with DOD to study PTSD/TBI planning on Congressionally Mandated programs • VA and DOD held a joint meeting on TBI research activities • VA, DOD, and MIMH met to discuss effective treatments for PTSD • The VA polytrauma QUERI includes senior DOD clinicians on the Executive committee • The VA is working with DARPA to test an upper arm prosthesis in the Cooperative Studies Program • The VA and DOD have had several meetings and discussions on regenerative medicine and a VA Center for Enhancement of Neural Repair was established • DOD has participated in OEF/OIF advisory committee meetings

Genomic Medicine The goal is to collect and link genetic information with the VA EMR system to find genetic predispositions to the causes and mechanisms of disease, to better define treatments, and establish how genetic information can be used in clinical medicine. 175 Federal Activities in Telemedicine, Telehealth, and Health Technology

The VA has a pilot program underway testing practical mechanics on how to collect genetic specimens as part of clinical trials, and to determine the best and most efficient way to collect and store DNA specimens. Over 25,000 specimens have been collected on veterans. So far, research has produced genetic information on schizophrenia, on Alzheimer’s, type 2 diabetes, and childhood anxiety disorders. Ongoing projects include studying serotonin and dopamine transporter genetics, cholesterol disorders, bipolar disorders, coronary disease in Mexican-Americans, and Gulf War veterans’ illnesses. Large scale genomic medicine projects include studying serious mental illnesses, deployment related mental illnesses, ALS, healthy 85 year or older veterans, and wound healing.

Rehabilitation Research and Development Service The VA’s approach to rehabilitation is to do basic research on how to repair and optimize functions of injured organs and tissues, prosthetics research to replace what cannot be repaired, translational research to bring basic discoveries to clinical use, and do clinical research to maximize function, and research to promote social reintegration. The Rehabilitation Research and Development Service (RR&D) researches effective treatments for preventing obesity but also investigates novel approaches and strategies to promote good health outcomes. The program as part of the Chronic Medical Disease portfolio is looking at technologies to help not only healthy obese persons but also help obese individuals that have serious injuries and other serious conditions such as spinal cord injuries, traumatic brain injuries, strokes, multiple sclerosis, ALS, and aging. Researchers are working in the area of biomedical and rehabilitation engineering to help find solutions for treating obesity. The program has dedicated $2.5 million to be awarded over the next five years to fund the Research Enhancement Award Program (REAP) solicitations in tissue engineering and patient safety.

Electronic Support for Patient Decisions The VA has a computer program to provide electronic support for patient decisions for VA medical centers. The customized software called iMedConsent provides patients with treatment options and information on standardized procedures among clinicians. The software developed for the VA’s National Center for Ethics in Health Care by Dialog Medical, takes physicians step-by-step through the informed consent process, displays detailed information concerning the risks and benefits of proposed treatments, generates and stores consent forms, incorporates electronic signatures into records, and imports information from patient records.

Patient Care Services Office of Care Coordination http://www.carecoordination.va.gov There are thousands of patients enrolled in Care Coordination Home Telehealth (CCHT) programs in 21 VISNs. The VA has spent $20 million to install some 20,000 monitors across the country. 176 Federal Activities in Telemedicine, Telehealth, and Health Technology

Coordination in the VA takes place in three areas:

• CCHT provides new technologies to home healthcare to patients with chronic diseases such as diabetes, congestive heart failure, chronic pulmonary diseases, depression, post traumatic stress disorder, spinal cord injuries, and wound care. The CCHT programs target two to three percent of the patients accounting for 30 percent of the costs. There are fewer hospital admissions and emergency room visits have been reduced by one-third. The VA provides home telehealth to patients in 21 VISNs. The program provides consults per year in 31 clinical specialties with active programs in all VISNs. The VA is buying home telehealth products in non-video measuring and monitoring, video telemonitors, and video telephones. Telehealth technology is being used to provide remote rehabilitation clinic access, and the LAMP program uses a variety of technologies including telephones, in-home messaging devices, monitors, and personal computers to help veterans who require personal assistance with at least two daily activities. The VA’s National Acquisi- tion Center awarded a national contract for “Care Coordination Home Telehealth in Home Messaging and Measurement devices.” • Care Coordination General Telehealth (CCGT) involves using videoconferencing technologies with peripheral devices between clinics and hospitals • Care Coordination Involving Store-and-Forward Telehealth (CCSF) has a primary care-based program that assesses veterans with diabetes for retinopathy using tele-retinal imaging that expedites referrals for treatment and provides health information.

The Office of Continuing Care’s strategic direction in general is to respond to the needs of veterans, define appropriate clinical interventions, choose the right technology, educate the workforce, implement the necessary business process to support programs, and do further research and development.

Telemedicine/Telehealth Examples of some of the VA’s major telemedicine/telehealth efforts:

• The VHA has established a national CCHT training center in Lake City, Florida to train care coordinators • The Rocky Mountain Telehealth Training Center has a “Just-in-Time” training program to help care providers become proficient with equipment they need to use • The Boston Telehealth Training Center offers two concurrent master preceptor classes • Doing a clinical trial on the effectiveness of home-based health messaging for patients with hypertension and type 2 diabetes • Telehealth is used in bariatric surgery clinics • The VA has identified a clinician lead, a research lead, and a field telehealth coordinator for teledermatology • In Michigan’s Upper Peninsula and in northeastern Wisconsin, the VA is using telepathology within a five state network integrating data, voice, video, and imaging systems. This network enables primary diagnosis and consultation in surgical pathology • The VA is implementing systematic coding systems for telemedicine 177 Federal Activities in Telemedicine, Telehealth, and Health Technology

• Home telerehabilitation continues to grow with a Low ADL Monitoring Program providing an important resource

Telehealth Program for Underserved and Native American Veterans The Telehealth program for high-risk underserved veterans and Native American veterans provides remote system access, telephone triage between patients and healthcare providers, teleconsulting, pacemaker surveillance, video conferencing, CMOP, ECG analysis network, teleradiology, telepathology, telemental health, teledermatology, telecare in diabetes, and teledentistry.

Paralyzed Veterans The VHA funds telemedicine in homecare projects to help paralyzed veterans. The main objective is to care for patients with spinal cord injuries who are transitioning from hospital to homecare so that they can remain in the community. These projects are based in 18 spinal cord injury and dysfunction centers located in 11 states. By using interactive audio visual conferencing and information technology, patients and healthcare providers can consult with specialists at the Spinal Cord Injury Center at the VA Palo Alto Health Care System. Patients and clinicians are participating in a virtual visit with SCIC staff. Assis- tance is given for spinal cord injuries, multiple sclerosis, post polio syndrome, and guillain-barre. During weekly sessions, the local clinicians and patients consult with experts in Palo Alto using videoconferencing, electronic patient records, digital radiology, and wound images.

Dental Record Manager Plus The DRM Plus is a fully integrated enhancement to the VA Computerized Patient Record System to provide the dental component to the VA electronic health record and is operational at all sites. The project also includes the development and the implementation of the local and national dental database and reporting system called the Dental Encounter System to integrate clinical dental images with the VA dental electronic health record.

VHA Polytrauma Telehealth Network The Network led by the Office of Care Coordination has established interactive connections between clinicians at 4 VA polytrauma centers and 21 Level II VA medical centers. The Network coordinates national trauma rehabilitation and educational services for patients recovering from traumatic injuries such as TBI, limb amputation, burns, and paralysis. Direct patient evaluation and consultation is also possible through the VTC network.

VISN Telehealth Activities and Services VISN 1 New England Healthcare System http://www.newengland.va.gov Northeastern University has partnered with VISN 1 to establish a new systems engineering center, The center, called the New England Healthcare Engineering Partnership, will help design innovative industrial engineering solutions to help the VA healthcare system. 178 Federal Activities in Telemedicine, Telehealth, and Health Technology

The Connecticut Healthcare System’s Continuing Care and Case Management Program have decreased the time that patients spend in the hospital by 85 percent, the time in emergency departments by 26 percent, and nursing home use by 21 percent. The VISN 1 Mental Illness, Research, Education, and Clinical Center found that using a computer- delivered coping skills training program boosts treatment success when added to a traditional outpatient treatment program. Seventy seven patients with drug abuse issues entering treatment were given either standard care or standard care along with the addition of a multimedia computer program based on the principles of CBT. In the study, patients using the computer-based program had fewer drug positive urine specimens and had longer periods of abstinence during treatment when compared to patients who only met with a counselor. The Togus Maine VA has successfully integrated a customized JVN telemedicine model expanding access to diabetes eye care. Telemedicine technology helps determine levels of DR, identify ocular and presumed systemic conditions, and enters patients into an eye or medical care program. Five telemedicine clinics open in rural Maine use computers and digital equipment to assist qualified veterans in rural towns. An ongoing telemental health program is in place, plus links provide conferencing, consultations, family interviews, and intervention. VISN 1 has completed Health Data Repository standardization requirements in all categories and has standardized equipment purchases along with developing an accurate system for tracking IT projects and potential pilot projects.

VISN 2 Healthcare Network Upstate New York http://www.visn2.va.gov VISN 2 in Upstate New York uses telemedicine technology to support re-engineering laboratory services, pathology processes, and videoconferencing at all five medical centers.

VISN 3 New York/ New Jersey Veterans Healthcare Network http://www1.va.gov/visns/visn03 VISN 3 provides services for spinal cord injuries and mental health including post traumatic stress disorder, and homeless services. The VAMC and New York University are using a neurosurgery imaging system to view imaging data during neurosurgical procedures between operating suites and designated offices. Images such as computerized tomography, magnetic resonance imaging, stereo views of angiography frames, and other modalities, enable consultants at the VA and NYU to be informed in real-time during surgery. The VISN cares for veterans with severe dementia plus the VHA is participating in a multi-site demonstration project on Alzheimer’s disease and care management.

VISN 5 Capitol Health Care Network http://www.va.gov/visn5 VISN 5 has a home telehealth program in Washington D.C., Martinsburg, West Virginia, and Baltimore Maryland, using VA computerized medical records. Baltimore and Washington D.C. also have a partnership that works with the East Coast Center of Excellence for MS. The Washington D.C. VAMC partners with the Walter Reed Army Medical Center to transmit digitized dental X-rays between facilities for consultative purposes. The DOD and VA medical facilities and 179 Federal Activities in Telemedicine, Telehealth, and Health Technology

dental labs will be part of one dental network. The Chief Cardiology Service in Pennsylvania maintains remote system access to the Altoona VAMC DHCP system. Specialized cardiology tests (angioplasty, cardiac catherization, thallium stress etc.) are performed on patients referred to the Washington D.C.VAMC, with the tests entered remotely into the patient’s automated medical records. Pacemaker Surveillance Center Program requires important follow-up pacemaker monitoring for thousands of patients annually. This is done in centers at the Washington D.C. VAMC, and at the San Francisco VAMC.

VISN 6 Mid-Atlantic Health Care Network http://www.visn6.va.gov The VA Medical Center in Durham North Carolina uses a teledermatology consult system with store and forward digital imaging technology for patients receiving teledermatology. The VAMC in Richmond VA has been a major referral center for solid organ transplants for two decades. Some patients have been using telemedicine for episodic care, pre-evaluations, and follow up care. Telemedicine reduces patient transfers, establishes stronger links with referring physicians, provides better patient care, and reduces costs for caregivers who must travel with the patient.

VISN 7 Atlanta Network http://www.southeast.va.gov VISN 7 use telemedicine to assess pressure ulcers. The system takes digital photographs of the ulcer, measures the ulcer areas and volume, and looks at clinical data collected by a nurse. The data is entered into a laptop, transmitted to a central database, where a computer program analyzes and posts the data to a web page for access by the consulting physician. VISN 7 has developed a telemedicine training program for mental health clinicians. Initial training rounds were done with mental health clinicians in Charleston, as well as at the Birmingham VAMC, and Huntsville Alabama CBOC. VISN 7 uses a telemental health strategy for the Iraqi veterans returning to South Carolina, Georgia, and Alabama.

VISN 8 Sunshine Healthcare Network http://www.visn8.med.va.gov The VA Florida Puerto Rico Veterans Integrated Service Network is shifting from inpatient to outpatient community and home-based care using technology to expand services. VISN 8 is an integrated system of seven hospitals, ten multi-specialty outpatient clinics, and 28 community-based primary care clinics. The program addresses telehealth and remote monitoring through disease dialogues, in-home messaging devices, personal computers, web cams, and wound care cameras. The VISN has launched a care management initiative targeting high-risk veteran populations that include the frail elderly, medically complex, and mentally ill. Clinical demonstration projects are located at various medical centers across the state of Florida and San Juan., where care coordinators use a variety of technologies such as monitoring patients in their homes and reducing hospitalizations and emergency room visits, while improving clinical outcomes, patient satisfaction, access, and lowering costs. The Rural Home Care Project (RHCP) was implemented as part of the VISN 8 Home and Com- 180 Federal Activities in Telemedicine, Telehealth, and Health Technology

munity Care Service Line and is one of 10 clinical demonstration projects serving 19 counties in southern Georgia and 37 counties in North Florida. The RHCP is a population management project using expert care coordination in combination with telecommunication to manage chronically ill veterans. The project features in-home monitoring done with a dialogue box and audio video equipment to monitor vital signs. The Tampa VA Medical Center has hosted a Research Enhancement Award Program to prevent adverse events in rehabilitation. They are studying patient safety, focusing on technology to manage patient falls, pressure ulcers, and pain. Some other programs in the VISN include:

• The Advancing Cancer Care through Technology (ACCTT) Project provides daily cancer monitoring and management to veterans and helps with chemotherapy • Lake City FL provides access to assisted living facilities, and care coordinators do home messaging and telemonitoring • Gainesville/Lake City Veterans Video Network specializing in PTSD uses personal computers and videoconferencing to provide therapeutic intervention through email and supervised chat rooms • Gainesville Diabetic Limb Preservation enables veterans and caregivers to receive information on their treatment using a special focus camera. The veterans and caregivers are taught how to photograph the healing wounds, and then the information is mailed to the care coordinator for follow-up phone care • Bay Pines program focuses on bipolar and schizophrenic veterans and uses in-home video messaging, email, and videophones • Ft. Myers enables frail patients and caregivers to use telemonitors, videophones and in-home messaging to communicate with primary care providers • West Palm Beach mental health program use in-home messaging devices and videophone technology • San Juan has both an urban and rural diabetic and SCI program that use telemonitors, in- home messaging devices. or cameras for wound care. Some of the patients live five hours away from access to any health care • Miami T-Care program focuses on frail older adults. The program works with diabetics but will expand to other diagnostic categories over time • VISN 8 in cooperation with the Volunteers of America has a mobile clinic specifically designed to provide care for homeless veterans and has a complete mobile dental clinic connected to VISN facilities and uses telemedicine technology • VISN 8 CCCS with NCI has established a steering committee to look at developing a cancer care model. The clinical model has been tested within the Tech Care Coordination Program at Lake City.

VISN 10 Healthcare System of Ohio http://www.visn10.va.gov Ohio VAMC’s use a two-way video teleconferencing system for psychiatry so that physicians have direct access to the records of psychiatric patients who live in underserved rural areas. Future applications may include distance learning. 181 Federal Activities in Telemedicine, Telehealth, and Health Technology

Veterans receive care in clinics across Ohio from staff physicians in the VAMC regional Spinal Cord Injuries Disorders unit. The telemedicine program uses a videoconferencing system integrated with network databases and specialized medical devices.

VISN 11 Veterans in Partnership http://www.visn11.va.gov VISN 11 has a strong program in home telehealth. In addition, VISN 11 has implemented a home tele-anticoagulation monitoring program, and a dementia telehealth program directed at supporting the caregiver rather than the patient. The Unobtrusive Home Health Monitoring System supports aging in place for veterans living alone who are unable or unwilling to interact with more usual telehealth technology.

VISN 12 Great Lakes Health Care System http://www.visn12.va.gov The Milwaukee VA Medical Center, Home Care Program uses telehome care to provide care to geriatric veterans residing in the rural counties surrounding the medical center. Two central tele-home base units and 18 patient stations were purchased through a local grant. The planning, implementation and maintenance of the telemedicine equipment are supported by the medical center’s telecommunications and biomedical engineering staff. The homecare staff uses telemedicine visits to provide assessments, manage chronic diseases, manage medications, provide dietary education, and coordinate community resources. The VA wants to use a decentralized eICU at potential sites plus install Clinical Information S ystems within every hospital in VISN 12. Presently the VISN has several clinical information systems with ICU sites using a combination of traditional paper charts along with VistA to manage critical care patients. The VISN is using telepathology with data, voice, video, and diagnostic imaging systems to create one of the of the largest specialty care telehealth networks in the U.S. The network can do real- time telefluoroscopy, teleradiology, and diagnostic video-conferencing. The Nuclear Medicine Network captures and displays nuclear medicine images at ten workstations strategically located in the medical center in Milwaukee. A Nuclear Medicine Teleconsultation Network transmits nuclear images from the Iron Mountain VAMC to the Milwaukee VAMC.

VISN 17 Heart of Texas Health Care Network http://heartoftexas.va.gov VISN 17 serves a population of over one million veterans residing in 134 countries. The veteran population in this large geographic area range from urban centers to largely rural areas. Several military installations in Central and South Texas offer many opportunities to collaborate with DOD.

VISN 18 Southwest Health Care Network http://www.southwest.va.gov DOD and Texas Technical University are working to provide telemedicine capabilities at three 182 Federal Activities in Telemedicine, Telehealth, and Health Technology

facilities in the VA Southwest Healthcare Network. Inoveon Service, a biotech company spun off from the University of Oklahoma has a digital retinal camera at the VA Medical Center in Oklahoma, where technicians take a series of images of the retina for every diabetic patient. These images are sent over the internet to the Inoveon reading center at Vanderbilt University where diagnostic technicians analyze the images. The retinal test score and a recommendation for follow-up are summarized and transmitted back to the doctor via the internet within 48 hours.

VISN 19 Rocky Mountain Network http://www.visn19.va.gov The Rocky Mountain Network VISN 19 is the largest VHA network in the contiguous U.S geographically speaking. Communications infrastructure in outlying areas is frequently primitive and most communities do not have ISDN or fiber optic capabilities. The Rocky Mountain Network provides voice, video, and data communications infrastructure. The Montana Health Care System has aggressively pursued a telepsychiatry initiative by equipping each site with a video conferencing unit. Telemental services were originally provided using a telepsychiatry link between the Cheyenne Wyoming VAMC and Vet Centers in Ft. Collins Colorado and Scottsbluff Nebraska. Telemental services are now used in most of the facilities in the VISN. The University of Colorado Health Sciences Center has a partnership with the Eastern Colorado Health Care System (ECHCS), Hot Springs South Dakota VAMC, Rosebud Indian Health Services and the Rosebud Tribal Veterans Center in South Dakota to provide services to Native American veterans suffering from Post Traumatic Stress Disorder (PTSD). The program is running a weekly five hour telemental health clinic out of ECHCS to the Tribal Veterans Center in South Dakota, to do intakes, medication management, intervention therapy, and maintain a weekly PTSD support group using video conferencing connections. The VISN is using an area wide network and is implementing a state-of-the-art teleradiology program with PACS at the ECHCS Denver facility and the SLHCS Salt Lake City facility. The VISN also provides telesurgery, teleretinal imaging, teledermatology, and telenutrition services Four facilities within the VISN are participating in a pilot program on managing chronic diseases with 100 veterans participating. Specific diagnostic categories were selected for the pilot, including CHF, COPD, and depression. Technology telecare managers monitor patients on a daily basis while educating them to better self-manage and understand their chronic conditions. The program has expanded to all of the facilities in the network to include diabetes, hypertension, and bipolar disorder. The Colorado VA is piloting a disease management program to let patients use a handheld computer to record and transmit information about their medical condition from their home. The VA is using handhelds that have large buttons and are simple to read in order to help caregivers monitor their patient’s health remotely. The VA expects to help patients with hypertension, diabetes, schizophrenia, CHF, chronic lung disease, and depression plus other diseases in the future. VISN 19 has been working on several telemedicine initiatives with VISN 20. One of the initiatives is the Spinal Cord Injury Application, a “hub and spoke” network that works in conjunction with Seattle and VISN 20. The system uses a PC and video conferencing network to connect patients at the Fort Harrison VAMS with specialized care at the Seattle VAMC. Another effort uses digital imaging to enhance the treatment of wounds. With digital cameras, the clinical staff captures wound images which are then transferred to the Sheridan VAMC as email attach- 183 Federal Activities in Telemedicine, Telehealth, and Health Technology

ments or attached to the medical record. This application has been used to enhance the consultation process for wound care between clinicians inside and outside of the VA.

Northwest Health Care Network (VISN 20) http://www.visn20.med.va.gov A telemedicine initiative in VISN 20 uses the Joslin Vision Network to provide diabetic veterans in the Montana Healthcare System access to quality eye care using an imaging system to use for the acquisition, storage, and retrieval of retinal images. The VA Puget Sound Health Care System in the Seattle VA Medical Center has a telemedical Can- cer Center between VISN 20 and regional cancer centers to increase access to treatment. The average age of the mostly male patients is 65 and many are treated at home and receive multi-disciplinary consultations. Five sites are using home telehealth with many devices going to patients. Telehealth requires a variety of methods for communications within and between sites and requires flexibility to accommodate the different needs and systems at each site.

Sierra Pacific Network (VISN 21) http://www.visn21.va.gov The VA Palo Alto HealthCare has a PACS to allow doctors to operate in a filmless environment. The cardiology and the gastroenterology suites transmit electronic records into PACS to store forms and advanced directives and to transmit the data to HealtheVet. Palo Alto has a charting application and data collection engine to automatically collect, manage, display, and store patient information for intensive care units. The VA’s Honolulu office has completed a network connection to 22 Pacific Island jurisdictions and to the State of Hawaii Telehealth Access Network (STAN). The network interconnects 18 private hospitals, the University of Hawaii, School of Medicine, Department of Public Health, and the University of Hawaii, School of Nursing. The STAN network uses fiber optics, digital microwave, coaxial cable, high- bit rate copper, ISDN, and satellite telecommunications links. The Veterans Affairs Medical and Regional Office Center in Honolulu with a grant from the Rural Health Care Division of the Universal Service Administration Company funds high-speed telecommunications circuits. The grant, the first to be awarded to a medical center within the VA, provides subsidies for the costs of broadband and high-speed circuits to connect VAMROC Honolulu’s Community Based Outpatient Clinics on the neighboring islands to Honolulu. The Honolulu VAMC has partnered with the School of Medicine, University of Hawaii to establish a link between the primary care satellite clinic and the Pacific Center for Post Traumatic Stress Disor- der using a telemedicine network called Tele-Education Applied to Community Health (TEACH). The network integrates a comprehensive range of technologies or tools into a single, simplified package for clinical, educational, and administrative use. Applications include real-time medical consultations, psychosocial consultations, administrative conferencing, in-service training, e-mail, scheduling, record transfer, and maintaining a reference library. 184 Federal Activities in Telemedicine, Telehealth, and Health Technology

Desert Pacific Health Care Network (VISN 22) http://www.desertpacific.va.gov The Loma Linda VAMC uses an Image Management and Communication System (IMAC) to integrate imaging resources, to connect through the hospital-wide fiber optic network linked to the Loma Linda Medical Center. The IMAC system links all Southern California and the Nevada Directors Asso- ciation networks for consultations, educational programs, and research activities. Telemedicine services will be expanded at the Reno VA Medical Center with telemedicine services provided between Reno, and Palo Alto, and San Francisco VA.

Midwest Health Care Network (VISN 23) http://www.visn23.va.gov The Midwest Health Care Network provides inpatient primary, secondary and tertiary care in medical, surgical, neurological, rehabilitative, short and long term psychiatry modalities, and surgical and mental health ambulatory care. The VISN uses telemedicine for diabetic retinal screening dermatology, orthopedics, post-op clinic visits, mental health services, and monitors congestive heart failure. Electronic chart reviews are being used in telemedicine clinics and results show a quick turnaround for 84 percent of the patients. Face to face appointments decreased from 10 patients per month to one patient, with cost savings resulting in $10,000 the first year, with a reduction in consultations going from 63 days to two days.

VA and CMS VISTA-Office EHR System Collaborative Effort The VA and CMS are collaborating on the VistA-Office electronic health record to be used in clinics and physician offices. The system based on VistA, will be streamlined and enhanced to make it appropriate and affordable for use outside the VA. Patient registration features of VistA are modified to reflect the requirements of smaller medical practices. Specialty components, such as ob/gyn and pediatrics are enhanced. The VistA-Office EHR can be adopted directly by physician offices, used by vendors who provide administrative support services to physician offices, or used by commercial software developers to make competitively priced products with similar functionality. Private developers, physician organizations, and healthcare purchasers are aware of the VistA-Office-EHR project. The project funded and co-managed by CMS and VHA coordinates efforts with IHS, HRSA, CDC, and FDA. Subsequent releases with changes and improvements are being made to the VistA system and developed in conjunction with the participating agencies.

Health Services Research and Development Centers of Excellence The VHA has established eleven Health Services Research and Development Centers of Excellence. The Centers search for the most cost-effective approaches to delivering quality health care to the nation’s veterans through the support of health services research studies. The Centers of Excellence have made major advances in wheelchair design, functional electrical stimulation, hearing aids, prosthetics, and in 185 Federal Activities in Telemedicine, Telehealth, and Health Technology

other areas. Three research centers established in Boston, New York and Miami are doing research to develop artificial retinas to restore sight to blind veterans and find new therapies for spinal cord injuries.

Veterans Health Initiative The Veterans Health Initiative recognizes the connection between certain health effects and military service, prepares healthcare providers to better serve veteran patients, and provides a database for further study. The development for this initiative began with the Military Service History project, which produced a pocket card for medical residents. The project is developing a comprehensive military history to be coded in a registry and available for education, outcomes analysis, and research. Any veteran can register their military history and automatically receive updated and relevant information on issues of concern. 186 Federal Activities in Telemedicine, Telehealth, and Health Technology

Department of Commerce http://www.commerce.gov Office of Policy and Strategic Planning Technology Council The Technology Administration within the Department of Commerce has been eliminated. A Senior Advisor in the Department’s Office of Policy and Strategic Planning now chairs a Department- wide Technology Council to coordinate technology policy activities across the Department in lieu of a stand-alone Technology Administration.

National Telecommunications and Information Administration http://www.ntia.doc.gov 2009 Stimulus Package Funding The American Recovery and Reinvestment Act of 2009 (ARRA) or stimulus package is providing $4.7 billion for NTIA’s Broadband Technology Opportunities Program and will be used to accelerate broadband deployment in unnerved, underserved, rural areas and funding will go to to strategic institutions that are likely to create jobs. $200 million will be used to upgrade technology and capacity at public computer centers, and $350 million is available to upgrade broadband inventory maps. A total of $7.2 billion in stimulus funding goes to not only NTIA, but also $2.5 billion goes to the USDA Rural Utilities Services to establish the “Broadband Initiatives Program” to extend loans, grants, and loan/grant combinations to facilitate broad band deployment in rural areas. In addition NTIA is working with the FCC together on broadband funding in their pilot program, and with USDA on their rural development broadband programs. On July 1, 2009, the first round of Recovery Act funding for $4 billion was made available for loans and grants to bring broadband service to communities. NTIA is responsible to fund $350 million in grants to develop and maintain a broadband inventory map. NTIA expects grant awards to range between $1.9 million and $3.8 million per state for the mapping portion of each project. In October 2009, NTIA awarded their first four grants. The grants went to the California Public Util- ities Commission for $2.3 million, to North Carolina’s e-NC Authority for $1.6 million, to Indiana Office of Technology for $1.3 million, and to the Vermont Center for Geographic Information for $1.2 million.

Public safety NTIA released a report to encourage the federal, state, and local public safety community to consider using commercial technologies in satisfying broadband interoperable communications among first responders. The report also recommends agencies consider commercial broadband services. NTIA awarded grants to assist public safety agencies in the acquisition, deployment, and training when using interoperable communications system. The goal of the Public Safety Interoperable Communi- cation Grant Program is to help state, local officials communicate during a natural or man-made disaster. The PSIC grant program funds interoperable communications projects to help state and local first responders improve public safety communications during disasters. 187 Federal Activities in Telemedicine, Telehealth, and Health Technology

NTIA and the FCC have established a Joint Advisory Committee to deal with communications capabilities for emergency medical and public healthcare facilities. The Committee is looking at communications needs, how to accommodate growth for services, and how to improve the integration for communications systems. NTIA along with other agencies is providing millions in E 911 grant funds to improve and update 911 emergency numbers to get help. This needs to be done because there are 255 million wireless telephones in the U.S and when a wireless phone is used, it is not always possible for the emergency responders to identify the caller. DOT’s, National Highway Traffic Safety Administration, and the Department of Commerce (NTIA) published a joint notice in the Federal Register proposing regulations for the E-911 Grant Program. The ENHANCE 911 Act of 2004, authorizes grants to operate Phase II enhanced 911 services and for migration to an IP-enabled emergency network. Now the New and Emergency Technologies 911 Improvement Act of 2008 amends the ENHANCE 911 Act of 2004 to permit grant funds to be used for migration to an IP enabled emergency network.

National Institute of Standards and Technology http://www.nist.gov NIST offers measurement tools and other assistance to clinical labs, medical manufacturers, hospitals, and drug makers. NIST is involved in nearly every area of medicine, and researches advances in biotechnology, information systems, and nanoscale devices to enhance healthcare quality and reduce costs. However, turning the research into marketable products and services requires advances in measurements and standards, data to help ensure the accuracy of diagnoses, and advances to improve manufacturing efficiency. The 2009 Recovery Act or stimulus package provides $220 million for NIST laboratory research, competitive grants, research fellowships and advanced research and measurement equipment. In 2009 NIST announced a grant program available with the funding from the stimulus package for competitive grants in the Measurement Science and Engineering Research Grants Program. $20 million was allotted from the Recovery Act to help NIST establish standards for Health Information Technology. In July 2009, NIST was given Recovery Act funding of $35 million for grants to support research in energy, environment and climate change, information technology, cyber security, biosciences/healthcare, manufacturing, and physical infrastructure. There are a handful of telemedicine related projects at NIST plus a number of programs related to developing standards in the healthcare field and these projects include:

• NIST is interested in working with regional, state, local economic development organizations, technology incubation centers, technology-oriented public-private business development initiatives, and other organizations and partnerships to develop potential licensing and/or collaborative arrangements • NIST research is needed to improve measurements and standards in the biosciences field. Research focuses on measurements for mass spectrometry and molecular imaging, new technologies for micro-fluidics and live cell imaging, and developing standards to exchange biological data and information 188 Federal Activities in Telemedicine, Telehealth, and Health Technology

• Producing screening tests for heart disease and cancer and other medical tests made possible by using NIST standards and calibrations. The NIST cholesterol measurement standards are part of a series of measurement standards designed to help clinical labs verify the accuracy of their measurements. NIST mammography standards help to ensure that clinical exposures are within regulatory limits • NIST is involved in the U.S. Measurement System Initiative “Imagining Metrology for Telemedicine” plus leading an effort to document measurement and measurement-related standards for the U.S. system-wide. NIST will not set the standards or serve as a regulatory body, but will work with others, as a neutral party on standards. Working with other stakeholders, NIST is preparing a “U.S. Measurement Needs and Opportunities Assessment”, and is publishing a U.S. Measurement System (USMS) Roadmap. The roadmap will be a comprehensive assessment of measurement related needs and plans and how to address the needs with updates published on a regular basis on what should be done by NIST and others to meet the needs of the USMS. • NIST in the Information Technology Laboratory works on interoperability and is involved in data analysis and modeling to provide open standards to be able to exchange clinical data, patient records, equipment data, and other electronic information. NIST is taking a leadership role in integrating healthcare standards into emerging e-commerce frameworks using XML. In addition to the XML standards for health care records management, the laboratory is also working on image document management such as x-rays and MRIs. • The laboratory has developed the IHE XDS Profile which is one of a series of health IT standards-based profiles developed by integrating the Healthcare Enterprise Project with private industry collaborative efforts. The IHE XDX profile supports a document based patient electronic health record to provide for secure scalable standards for indexing clinical documents, and for finding and retrieving documents • The laboratory has developed the ISO 11073 Point-of-Care Medical Device Communica- tion Standard to enable medical devices to provide plug and play interoperability • The Image Quality Laboratory is developing digital motion imagery and tools to compare images on different platforms, including cinema, computers, and personal digital assistants • NIST and the Video Electronics Standards Association are developing an international flat panel display standard to become the basis for flat panel display measurements worldwide. By using the standard, the Mayo Clinic in Scottsdale Arizona saves $1.5 million per year and has switched from traditional radiographs (x-ray photo images viewed on light panels) to digital images viewed on flat panel displays. The clinic used the standard to purchase 1,000 flat panel displays for radiology knowing that the digital images would duplicate the quality of film. • NIST along with standards development groups and others developed a web-based repository of information called the Health Care Standards Landscape (HCSL). The repository provides a comprehensive source of information on healthcare standards, on standards development organizations, and organizations that use or implement healthcare standards. This information helps coordinate and develop more compatible standards and tools. The National Alliance for Health Information Technology has donated its database of 2,100 healthcare IT standards to NIST to be incorporated into the HCSL. • Diagnostics-nuclear medicine relies on NIST standards to protect patients receiving radio- 189 Federal Activities in Telemedicine, Telehealth, and Health Technology

active isotopes in cardiac stress tests, thyroid scans, bone scans, and other scans of vital organs to diagnose conditions such as heart disease and cancer. When hospitals and clinics measure the radiation levels of these isotopes, they use instruments that manufacturers have calibrated against NIST standards. NIST researchers are working on standards to help assure the accuracy of future diagnostic tests based on new knowledge about heart disease, cancer and inherited diseases. The NCI asked NIST to help evaluate and standardize biomarkers • The Manufacturing Engineering Laboratory is applying manufacturing technology to healthcare informatics and developing medical devices since healthcare and manufacturing share many similar organizational, technological, and informational issues. For example, the program has developed the HLPR Chair which is a patient assist device that provides independence for wheelchair users • NIST researchers are working with other scientists on a new medical treatment called inhaled nitric oxide therapy to assist newborns with a potentially fatal lung disorder, and per- sistent pulmonary hypertension. The National Institute for Child Health and Development asked NIST to develop a NIST traceable gas standard to accurately measure trace levels of nitric oxide, and FDA has approved the therapy. NIST and FDA are working with doctors and instrument manufacturers to develop written protocols for inhaled nitric oxide therapy medical devices tests as part of a program called the Early Detection Research Network • Researchers are studying RFID systems to define how many tags are needed and where they should be placed, develop a prototype RFID reader, and integrate the reader and navigation hardware and software into a wireless network to relay position information to others such as an emergency incident commander • The optical communications and computing program is addressing a new generation of transmission and networking technologies

NIST’s R&D goal is to develop measurements to accommodate higher speed and next generation communications networks, develop measurements to diagnose and locate transmission problems on data networks, develop new techniques to analyze computer circuits to transmit light instead of electricity, and develop ways to manipulate light within computer chips to interconnect very small electronic and optical devices.

HIPAA Security Standards Guide NIST’s Information Technology Laboratory released NIST Special Publication (SP) 800-66 “An Introductory Resource Guide for Implementing the Health Insurance Portability and Accountability Act Security Rule” to help with HIPAA’s security rule and to explain the minimum requirements and the systems needed to comply. Resources are provided on specific security standards included in the rule.

Biosciences NIST is developing accurate bioscience measurements so that healing can be accurately diagnosed. The goal is to find new methods for simultaneously measuring hundreds to thousands of molecules at a time by developing and validating new technologies in areas such as microfluidics and live cell imaging. NIST wants to help laboratories more easily compare and combine their measurements and computer 190 Federal Activities in Telemedicine, Telehealth, and Health Technology

models with one another by developing the right standards. In addition, NIST wants to make biological data more quantitative and reliable by developing methods, standards, and benchmark data to use for fundamental measurements.

Nanotechnology Nanotechnology, the science and technology of developing the smallest objects made by humans will be a dominant force in the 21st century. The future could bring advances such as microscopic robots about the size of human blood cells that will travel through the body to deliver drugs where needed. Nanotechnology will make possible new opportunities in healthcare, electronics, and other sectors of the economy. For example, “lab on a chip” devices can enable rural areas to have the most advanced healthcare technologies. As part of a multi-agency effort, NIST has an initiative to help U.S. industry accelerate the commercialization of new discoveries in this field.

Collaborations NIST collaborates with partners in a variety of ways to include informal collaborations, cooperative research and development agreements, and guest researcher arrangements. The Federal government and industry are establishing an international online forum for collaboration that aims to accelerate the development of products with ultra small dimensions while minimizing potential environmental, health, and safety risks.

Advanced Technology Program http://www.atp.nist.gov The Advanced Technology Program funded high-risk research and development. Public law 110-69 eliminated the ATP but allows for continued support for previous and pending ATP awards.

Technology Innovation Program The President signed the America COMPETES Act to authorize funding for NIST for the next three years which makes it possible for NIST’s core programs (laboratories and facilities) to double their R &D budgets over the next 10 years. The Act created the “Technology Innovation Program” to speed the development of high risk transformative research targeted to address key societal challenges. Through the program, funding can be provided to industry (small and medium sized businesses), universities, and consortia for research on potentially revolutionary technologies for meeting critical national needs that present high technical risks. Support will be given in the form of cost shared research grants, cooperative agreements, or contracts. Awards are limited to no more than $3 million total over three years for a single company project or no more than $9 million total over five years for a joint venture. In 2009, NIST sought “white papers” from academia, federal, state, local government, industry and professional organizations to assist the program to further define topic areas needed for development. Among the topics were personalized medicine, and complex networks and complex systems. 191 Federal Activities in Telemedicine, Telehealth, and Health Technology

Economic Development Administration http://www.eda.gov The 2009 stimulus package provided the Economic Development Administration with $150 million. The administration is set up to help generate jobs and stimulate growth in distressed areas. Assistance is available to rural and urban areas with severe economic distress.

International Trade Administration http://www.trade.gov/index.asp The International Trade Administration (ITA) has market information for exporters with medical devices and information technology data available by country and industry. Reports on countries and specific industries, analyze trends and describe economic, cultural, and political factors within regions and countries. ITA organizes trade missions to match U.S. companies with qualified agents, distributors, representatives, licensees, and joint venture partners in healthcare technology related markets. The report “Global Import Regulations for Pre-Owned Medical Devices” collects and compiles information on regulations relating to the importation of pre-owned capital medical equipment and includes information on market demand.

Trade Information Center The Trade Information Center within the U.S. Commercial Services helps companies find market information opportunities. The Center launched the India Business Center (http://www.export.gov/india) to help companies find emerging market opportunities within the fast growing middle class in India. Key sectors include education services, computers and peripherals, medical equipment, and telecommunications.

HealthCare e-Market Express http://buyusa.gov/eme/healthcare.html The Healthcare e-Market Express was created to provide healthcare companies with new healthcare market research, and trade leads received from embassies and consulates. Research information is sent out on biotechnology, clinical chemistry and other clinical laboratory science, dental equipment and supplies, healthcare services, medical devices and instrument, information and communication technology, and nutritional supplements and pharmaceuticals.

Market Development Cooperator Program http://www.trade.gov/mas The MDCP is a competitive matching grants program to build public and private partnerships by providing federal assistance to non-profit export multipliers such as states, trade associations, chambers of commerce, world trade centers, and other non-profit industry groups to work with small and medium- sized enterprises. The MDCP awards help to underwrite the start-up costs of exciting new export marketing ventures. Funding was made available for the program in 2009. 192 Federal Activities in Telemedicine, Telehealth, and Health Technology

Department of Agriculture http://www.usda.gov

Rural Utilities Service http://www.usda.gov/rus/index.html In 2009, Recovery Act funding was made available to RUS to deploy broadband to rural communities where it is needed. The “Broadband Initiatives Program” was put in place to extend loans, grants, and loan/grant combinations to facilitate broadband deployment in rural areas. In July 2009, application opportunities were announced to receive ARRA funds were announced. USDA in normal funding spends about $500 million per year on its rural telecommunications program, and has spent billions in loans and grants, resulting in more than one million miles of phone lines and thousands of miles of fiber optic cable being built. RUS is also a credit agency to help rural electric and telephone utilities obtain financing for projects to help communities.

Broadband Opportunities for Rural America http://wireless.fcc.gov/outreach/ruralbroadband USDA and FCC have launched an online resource to use to help deliver broadband services to rural communities. The web site presents the USDA and FCC resources in a single easily accessible location and user friendly format. The site provides information on the different technology platforms that can be used to provide broadband service, how to access the spectrum necessary to deliver wireless broadband services, the availability of government funding for broadband services, relevant USDA and FCC pro- ceedings and initiatives, and data on broadband deployment.

Rural Development Community Facilities Program USDA is funding $58 million for 102 rural community facilities projects with funds available through the stimulus legislation. So far, $179.6 million has been made available for facility projects. The program finances essential community facilities to provide first responder equipment, to update technology needs, and to build new construction.

Broadband Community Connect Grants http://www.usda.gov/rus/telecom/commconnect.htm In 2009, through normal funding, USDA accepted applications for the grants to bring broadband services to rural areas. The grants range from $50,000 to $1 million with $13,406,000 available. Grants go to schools, libraries, education centers, healthcare providers, law enforcement agencies, public safety organizations, as well as residents and businesses. In November 2009, 22 projects were selected in ten states to receive $13.4 million in Broadband Community Connect Grants. 193 Federal Activities in Telemedicine, Telehealth, and Health Technology

Broadband Telecommunications Loans http://www.usda.gov/rus/telecom/Broadband.htm The loan program creates public private partnerships to finance the construction of telecommunications infrastructure in rural areas.

Rural Development Broadband Access Loan and Loan Guarantee Program The low interest loan program enables loans to be made to deploy broadband services to communities with a population of 20,000 or less. In 2009, Open Range Communications finalized a $267 million loan agreement to provide broadband service to 518 communities in 17 states.

Rural Development Economic Development Loan and Grant Program The program provides no-interest loans to rural development utility program borrowers who then lend the money to local entities to promote economic development and to create jobs. In 2009, USDA accepted applications for $45.8 million in loans and grants.

Assistance for Native American and Native Alaskan Communities RUS is working to improve infrastructure services in many Native American communities and has financed over 60 local exchange carriers to serve tribal reservations. RUS has almost $660 million available for telecommunications infrastructure financing and another $1.45 billion in broadband infrastructure financing available to Native American entities that are eligible to apply.

Distance Learning and Telemedicine Grants http://www.usda.gov/rus/telecom/dlt/dlt.htm The 2009 stimulus package provides $2.5 million for loans and grants with no deadline set for expenditure of the funds, and no matching requirements. In 2009, grants were awarded in 35 states for $34.9 million. RUS administers the Distance Learning and Telemedicine Grant (DLT) Program) to promote and modernize telecommunication services in rural America. Three kinds of financial assistance provided include grants, loans, and combination loan/grants. DLT specifically funds projects that deliver critically needed education and medical services by developing interactive educational training over distances. These sites link to rural hospitals, medical clinics, medical centers, experts, and provide clinical interactive video consultations. The program is looking for proposals to provide networking to multiple dispersed sites over a geographic area rather than a single stand-alone entity. Projects are funded to be self-sustaining without the need for further grant or loan funding. The DLT program requires 15% in matching contributions, plus a $50,000 minimum and $500,000 maximum investment. These grants can be used to lease or purchase computer hardware and software, audio and video equipment, computer network components, terminal equipment, inside wiring, interactive video equipment, and instructional programming. Technical assistance is provided on equipment and systems, studies, analyses, designs, reports, manuals, guides, and literature. The loan and grant combination accepts applications year round. The funding goes for medical or 194 Federal Activities in Telemedicine, Telehealth, and Health Technology

educational equipment, to establish links between teachers and students or medical professionals in the same facility, for site development or alteration of buildings, for purchasing land and constructing buildings, and acquiring transmission facilities provided that no facilities exist.

Internet Dial-Up Service Grants Internet Dial-up Service Grants have been awarded with grants going to provide local internet services to Alaska, and another grant going to the smallest telephone company in Texas to be able to offer wireless local dial-up internet services. The grants finance the acquisition, construction and installation of equipment, facilities, and systems to provide dial-up internet access services to rural communities, and may also be used to fund costs for leasing transmission equipment, facilities, and systems for up to two years.

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Department of Energy http://www.energy.gov The Department of Energy is involved in health IT, telemedicine, and related projects at Argonne National Laboratory, Sandia National Laboratory, Oak Ridge National Laboratory, Los Alamos National Laboratory, Lawrence Berkeley National Laboratory, Lawrence Livermore National Labora- tory, Brookhaven National Laboratory, Pacific Northwest National Laboratory, Ames Laboratory, and the Idaho National Laboratory.

Safety and Health The Office of Health Safety and Security guarantees safety of the workforce and safe operations. Worker health programs and information cover a broad range of health issues from radiation exposure to dealing with cancer risks.

Office of Biological and Environmental Research Office of Science Medical Applications Researchers are taking the beneficial applications of nuclear and other energy related technologies and applying the information to biomedical research, medical diagnosis, and treatment. Researchers want to be able to use radiochemistry to develop new radiotracers for medical research, for clinical diagnosis and treatment, for the next generation of non-invasive nuclear medicine instrumentation technologies, and for the development of advanced imaging detection instrumentation capable of high resolution from the sub-cellular to the clinical level. The goal is for DOE engineering, physics, chemistry, and computer sciences to develop the basic tools to be used in biology and medicine particularly in imaging sciences, photo-optics, and biosensors.

Life Sciences Research Life Sciences Research is using DOE’s resources and facilities to develop knowledge of biological systems. The Life Sciences Research program with the Advanced Scientific Computing Research program is using computational resources, tools, and technologies to understand and to predict the complex behavior of complete biological systems. The researchers are looking at high throughput and cost effective DNA sequencing capacity to be able to meet the DNA sequencing needs of the scientific community. The researchers are also interested in understanding human genome organization, human gene function and control, and the functional relationships between human genes and proteins at a genomic scale.

DOE Laboratories Argonne National Laboratory http://www.anl.gov 196 Federal Activities in Telemedicine, Telehealth, and Health Technology

Biochips ANL is working on biological microchips or biochips and related technologies to permit faster and more efficient detection of genetic mutations, and has developed portable biochip microarrays capable of detecting and identifying anthrax and other bioagents. The initial market for biochips will be pharmaceutical companies, research facilities, biotech firms and academic research institutions worldwide. Ulti- mately, biochips will be used in hospitals and clinical laboratories. The clinical diagnostics market alone will be billions of dollars as these biochips are used to test for a wide variety of life threatening conditions, such as genetic defects and viral and microbial diseases.

Nanoparticles Magnetized nanoparticles may one day be used to treat people detoxing. The nanoparticles designed by the laboratory are fitted with receptors to identify and attach to target molecules, injected into the bloodstream, and then go through the body and pick up toxins. In order to remove the toxins, a handheld unit with a magnet and a dual channel shunt is inserted into the arm or leg artery.

Bioterrorism and Emergency Response The laboratory is developing instruments and sensors to detect chemical and biological agents in air, water, and soil. The laboratory provides technical assistance in emergency situations and deploys fast response systems for protecting first responders, decreasing exposure times, estimating population exposures, and reducing risk. ANL’s Decision and Information Sciences Division developed a tool called the Emergency Re- sponse Synchronization Matrix (ERSM). The software tool helps emergency managers develop crisis plans to coordinate actions across jurisdictions over an extended period of time. Running on a PC, the software organizes and displays the activities by jurisdiction, function, and time for easy review and analysis. The software helps outside responders assimilate into a community’s response effort and to quickly assess where the ongoing operation is needed. The system also enables emergency managers to consider “what if” scenarios before and during a response and can develop and run simulated events. Software has created a database with a list of individuals with special needs throughout a given emergency planning area. The special needs population includes the physically, mentally, and medically disabled individuals without transportation, and latchkey children.

Sandia National Laboratory http://www.sandia.gov Information Technology Sandia is one of more than 50 users and providers of advanced information technologies particularly in the areas of health care, education, government, and industry. The potential for hackers to intercept medical data in transit or to access confidential information stored in online repositories can be a real problem. Sandia researchers have developed computer component architecture to allow consumers to assemble off-the-shelf medical equipment in a manner similar to a home stereo system. This means that hospitals and individual patients will buy the equipment needed. This framework however will incorporate built in security mechanisms to protect the exchange of information between system components. 197 Federal Activities in Telemedicine, Telehealth, and Health Technology

Sandia National Laboratory and Celera Genomics have signed a Cooperative Research and Development Agreement to develop the next generation software and computer hardware solutions to be specifically designed for the demands of computational biology as well as a full range of life science applications.

Emergency Response Researchers are developing a sophisticated tool to assist government officials and others in emergency response. The program, initially designed for public health officials was produced by Sandia’s Weapons of Mass Destruction Decision Analysis Center. The Visualization Design Center allows users to comprehend complex issues and situations by using advanced computers, display systems, and software tools to simulate an attack based on real and projected data. Researchers will be able to integrate information on symptoms, and illnesses gathered from local hospitals to accurately simulate and understand the impact of identifying trends as early as possible. A computer model has been developed that can determine the number of people likely to be infected during an epidemic and die from non communicable illnesses like anthrax or any ailments caused by a potential bioterrorist attack as well as communicable diseases like smallpox. Sandia is working with the New Mexico Department of Health to detect disease outbreaks more quickly than traditional reporting methods. The Rapid Syndrome Validation Project (RSVP) can detect high numbers of symptoms before epidemics occur, and help public health officials determine disease and illness patterns. In the future, the program will be expanded to more sites along the US Mexican border. Researchers are working on a portable ultrasound device that emergency personnel can use at an accident site to detect brain injuries. The device is non-invasive, portable, relatively inexpensive technology, and can accomplish what CAT scans can do, plus will be useful for health professionals in hospitals.

Eye Research The laboratory as part of a multi-institutional multi-disciplinary team is developing a nano-sized battery that in the future can be implanted in the eye to power an artificial retina. The funding is part of a five year grant awarded by the National Eye Institute. The established the National Center for Design of Biomimetic Nanoconductors based at the University of Illinois Urbana-Champaign where bio batteries are being designed to use for a wide array of implantable devices. In another research project, Sandia with four other national labs, a private company, and two universities are working on a project to enable the blind to see. The project is funded with a three-year grant from the Department of Energy’s Office of Biological and Environmental Research. The idea is to create 1,000 points of light through 1,000 tiny MEMs electrodes. The electrodes will be positioned on the retinas of those blinded by diseases such as age-related macular degeneration and retinitis pigmentosa. These diseases damage rods and cones in the eye that normally convert light to electrical impulses, but leave the neural paths intact to the brain that transport electrical signals. Eventually the input from rods and cones ceases, but 70 to 90 percent of nerve structures are set up to receive those inputs remains intact. A tiny camera and radio-frequency transmitter is lodged in the frame of a patient’s glasses to transmit information and power to modules placed within the eyeball. The modules linked to retinal nerves send electrical impulses to the brain for processing. 198 Federal Activities in Telemedicine, Telehealth, and Health Technology

The Sandia approach is to attach a MEMs chip on the retina made of LIGA and surface micro- machined silicon parts. The idea is to directly stimulate some of the nerve endings within the retina to produce images good enough to read large print and to distinguish between objects in a room.

Smart Scalpel Mechanism In another research project, Sandia has developed a prototype “smart scalpel” mechanism to detect the presence of cancer cells as a surgeon cuts away a tumor obscured by blood, muscle, and fat. The dime sized device called a biological microcavity laser helps surgeons more accurately cut away malignant growths while minimizing the amount of health tissue removed.

Medical Diagnosis Researchers are developing a device to let patients in the doctor’s office provide a sample of saliva or blood, so the doctor can know in minutes if they are prone to heart disease, gum disease, or cancer. The researchers are developing a five pound hand-held medical device for doctors to use to do their medical diagnosis.

Devices to Help Diabetics and Heart Attack Patients A tiny device called ElectroNeedles developed at the Laboratory means the elimination of pain- ful blood drawing by diabetes patients to test glucose levels. Two arrays of micron-sized needles operate similarly by penetrating painlessly into the skin. Arranged in varying numbers on a small patch, the needles can measure molecules inside the body, eliminating the need to withdraw blood from a patient. Another device called the uPost has micron-sized posts that have the potential to painlessly measure proteins and other macromolecules, including protein markers released during heart attacks by using optical measurement. The platforms complement each other and together create a diagnostic suite capable of detecting many important biological markers. The uPost can be tailored in size to sample different portions of the skin. For example, they can be made shorter to measure small molecular weight compounds such as glucose in the upper layer of the skin, or they can be made longer to measure larger molecules in the blood, such as Troponin I, a key protein released when a person has a heart attack.

Biomedical and Bioinformatics Program The biomedical program is working on assistive technologies to develop technical solutions to problems experienced by mobility-impaired people. The program also has developed image analysis and pattern recognition software tools to aid radiologists in screening mammograms for cancer. A clinical trial demonstrated that by using the software, the odds of spotting certain cancers without increasing the risk of unnecessary biopsy or follow-up increases. The bioinformatics and computing program is developing a variety of modeling and simulation tools to analyze complex biological systems. This program helps researchers understand entire cells and gain understanding of biomolecular processes. 199 Federal Activities in Telemedicine, Telehealth, and Health Technology

Databases The purpose of Sandia’s Intellectual Property Available for Licensing (iPAL) database is to showcase Sandia technologies that may not be fully utilized in the commercial marketplace to help companies move promising technologies toward commercialization. The Center for Integrated Nanotechnologies has a database to help nanotechnology researchers search for federal government nanotechnology funding sources. The database currently lists sources from federal agencies along with solicitation numbers, amounts of funding available, descriptions, and other relevant information.

Oak Ridge National Laboratory http://www.ornl.gov Complex Biological Systems Program ORNL’s research program under the Complex Biological Systems Program draws on capabilities in engineering, end-use technologies, mammalian genetics, and scientific computing. The life sciences program researches functional genomics, biotechnology, bioengineering, computational biology, and bioinformatics, and works on high-performance computing with emphasis on computer and computational science, networking and intelligent systems.

Neuron Research ORNL and St Jude Children’s Research Hospital are doing research on how developing nerve cells may hold a key to predicting and preventing diseases like Cancer, Alzheimer’s and Parkinson’s disease. For the first time, scientists can use ORNL developed software to analyze vast amounts of data on change in nerve cells in record time.

Nanosensor Technology Researchers have developed a nanoscale technology for investigating biomolecular processes in single living cells. The new technology enables researchers to monitor and study cellular signaling networks including the first observation of programmed cell death in a single live cell. The nanobiosensor allows scientists to physically probe inside a living cell without destroying it.

Technology for Epileptics ORNL is working on helping patients with epilepsy where no available therapy is effective by developing a technology called SeizAlert. The device is a low cost compact wearable device that uses brain wave data from four scalp electrodes at the front of the head and converts the information received into usable data to determine if an epileptic seizure will be occurring. This device can improve the quality of life for people with epilepsy, but can also have other uses such as remotely monitoring soldiers in the field.

Help for Parkinson’s ORNL is advancing therapy for Parkinson’s and other diseases. The laboratory is developing a de- 200 Federal Activities in Telemedicine, Telehealth, and Health Technology

vice that will be able to monitor the delivery of healthy cells. Researchers are miniaturizing a device that physicians will be able to use to treat patients with Parkinson’s syndrome, brain tumors, and other diseases. The device is a catheter equipped with a fiber optic probe to perform fluorescence-based cyto- metric measurements on cells as they exit the port at the catheter tip.

Medical Device Joint Development ORNL researchers are working with Noninvasive Medical Technologies to improve and miniatur- ize a medical device to monitor hydration or fluid levels. The technology will help in better hydration management and help treat soldiers and others suffering from a fluid electrolyte imbalance. Studies have shown that up to 8 percent of the troops become dehydrated while performing their duties. ORNL is able to contribute their expertise in the area of chip design.

Technology Transfer ORNL’s Office of Technology Transfer is responsible for cooperative research and development agreements (CRADAs) and technology licensing. Some partnerships involving both licensing and CRADAs include:

• ORNL researchers have improved a device that monitors a person’s hydration level • Researchers devising a commercial inkjet technology for dispensing microscopic drops of biological fluids at high speeds, to be used to hasten the development of new therapeutic drugs. • Qgenics Biosciences a Knoxville start-up company has a miniaturized platform technology developed at ORNL that quickly diagnoses disease, and analyzes DNA proteins and other molecules. The technology called the Molecular Comb has numerous lab-on-chip applications, including environmental monitoring, point-of-care diagnosis, and post genomic protein research. Another application will help high throughput drug discovery • Caliper Technologies Corporation has a lab-on-a-chip technology to enable experiments to be conducted on a chip small enough to fit in the palm of a child’s hand • Three start-up companies have developed biochip technology and currently hold licenses related to the technology. The system can identify infectious disease strains in less than 15 minutes when testing protein arrays and in less than two hours when testing nucleic acid arrays.

Laboratory Directed Research and Development Program ORNL helps people at risk of becoming blind by using technology that was originally used to understand semiconductor defects. The project uses the laboratories proprietary content-based image retrieval technology, which is a method for sorting and finding visually similar images in large databases. The laboratory has adapted the technology and combined it with new image gathering and analysis tools to create a database to assist in the diagnosis and treatment of diabetic retinopathy, glaucoma, and age related macular degeneration. This project will be used for diagnosing and treating blinding diseases in broad-based population screening programs, but also for novel biomedical imaging and for providing telemedicine services. 201 Federal Activities in Telemedicine, Telehealth, and Health Technology

Los Alamos National Laboratory http://www.lanl.gov Researchers are developing new tools to characterize biological pathogens that could give rise to potentially deadly pandemics such as H1N1. The system will be able to automatically determine the genetic sequence of viruses such as influenza hundreds of times faster than any other method now available. A $1.7 million BioCel Automations system was developed in a joint effort between Los Alamos, the University of California at Los Angeles School of Public Health, and Agilent Technologies to enable public health officials to rapidly and reliably determine the strain of a virus.

Bioscience At Los Alamos, projects may involve molecular and structural biologists, biochemists, geneticists, computer scientists, engineers, mathematicians, materials scientists, and physicists. The Bioscience Division provides a multidisciplinary mix of capabilities focused on bio threat reduction, functional genomics, structural genomics, complex biosystem modeling, and biomedical technology. The Center for Human Genome Studies resides within the Division. The laboratory with collaborators from the University of Cambridge, and the World Health Organi- zation National Influenza Center at Erasmus Medical Center in Rotterdam Netherlands, have developed a computer modeling method for mapping the evolution of the influenza virus. This method may help researchers develop a better understanding of certain mutations in influenza and other viruses that allow diseases to dodge the human immune system.

Biological Systems The Biological Aerosol Security and Information System (BASIS) is a biothreat detection and characterization technology to protect civilian populations against terrorist aerosol releases of microorganisms capable of inducing lethal infections by identifying the location and time of release. The B-SAFER system is a disease management system with some surveillance capabilities to scan both standard and nontraditional sources of health information to develop an early warning system for potential outbreaks. The researchers take automatic feeds from the admitting system, look at medical records, lab results, ambulance run sheets, and a multitude of other sources for early detection. Scientists have developed a simulation model that can make predictions on the future course of an avian influenza pandemic. The simulation can tract the spread of infection through a synthetic population of 281 million people over the course of 180 days.

Bioinformatics The bioinformatics program is working with the biomedical and computational community to find ways to close the knowledge gap resulting from the enormous numbers of databases that are available from the information generated by technological advances. The work in bioinformatics tracks molecular epidemics, studies cellular responses to infections, and deciphers statistical data from clinical trials. 202 Federal Activities in Telemedicine, Telehealth, and Health Technology

Technology Transfer The laboratory seeks partnerships with biotechnology, pharmaceutical, medical device, and healthcare technology companies. The mechanisms for partnering include cost-shared, cooperative research and development agreements, sponsored research and development agreements that contract with the laboratory, user facility agreements, and the licensing of technology.

Lawrence Berkeley National Laboratory http://www.lbl.gov Life Sciences The Life Sciences Division works on computation, bioinformatics, cutting edge imaging technology, and structural cell biology to further understand the complexity of biological systems. The Division researches human diseases, coronary artery disease, biology of breast cancer, metabolic studies of neurological diseases, and disorders of red blood cell formation. The Cell and Molecular Biology Department studies controlling the normal growth and the development of a variety of tissues, researches stem cells to explore possible health hazards in space travel, and identifies the genes that influence rates of aging. The researchers are working to expand the ability to profile a patient’s genetics. They have invented a technique in which DMNA and RNA assays—the key to genetic profiling and disease detection can be read and evaluated without the need for elaborate chemical labeling or sophisticated instrumentation. The laboratory researchers have created a unique ultra-high density memory storage medium that can preserve digital data for a billion years. This research is needed since today’s silicon memory chips can hold their information for only a few decades. New memory storage can pack thousands of times more data into one square inch of space than conventional chips.

Lawrence Livermore National Laboratory http://www.llnl.gov The medical technology program does medical device research and is part of a broadly based program in the biosciences that encompasses several disciplines across the laboratory. The program researches cost effective treatment for acute stroke, cancer detection and therapy, diabetes treatment and diagnostics, and therapy for other prevalent diseases. The bioegineering research program is working on medical device projects that include breast cancer R&D, pathology and functional diagnosis and treatment, and on using a high-speed ultrasound sensor for breast imaging. The Biology and Biotechnology Research Program conducts multidisciplinary research to understand the genome and the relationship to disease susceptibility, and researches biomarkers, bioinstrumen- tation, bioinformatics, and computational biology.

Emergency Response Seattle Washington was the first city to participate in a National Nuclear Security Administration 203 Federal Activities in Telemedicine, Telehealth, and Health Technology

pilot project to help local communities plan for and respond to releases of chemical or biological agents. Under this initiative, local agencies are able to access the NNSA’s National Atmospheric Release Advi- sory Center (NARAC) at LLNL which predicts chemical, biological and nuclear plumes. The program called the Local Integration of NARAC with Cities (LINC) will eventually provide a unified tool for city, county, state and federal agencies to use in emergency planning and response. With the LINC program, initial predictions using the end user’s computer are available in less than a minute. NARAC predictions can easily be distributed to multiple users such as local, state and federal government agencies.

Cancer Research LLNL has partnered with San Jose based BioLuminate, Inc. to develop “Smart Probe” a tool to detect breast cancer detection earlier. The tool removes no tissue achieves accuracy levels comparable to surgical biopsies in detecting cancerous cells. The Smart Probe is smaller than the needle used in routine blood tests and is inserted into breast tissue after an initial screening indicates an area of concern. Once a mammogram or physical exam has detected a possible malignant lump, “Smart Probe” is inserted into the issue and guided to the suspicious region. Sensors on the tip of the probe measure optical, electrical and chemical properties that are known to differ between health and cancerous tissues. The probe can detect five to seven known indicators of breast cancer, with tissue measurements made in real- time in both normal and suspect tissues. Computer software compares the real-time measurement to a set of known archived parameters that indicate the presence or absence of cancer. The PEREGRINE program at LLNL works to improve the effectiveness of radiation therapy in treating cancer and has produced comprehensive nuclear and atomic databases to produce three dimensional dose calculations for all forms of radiation therapy.

Brookhaven National Laboratory http://www.bnl.gov Joint Center for Translational Biomedical Imaging The Laboratory and the Mount Sinai School of Medicine have established a Joint Center for Trans- lational Biomedical Imaging to identify new molecular targets for radiotracer development and provide access to a broad base of patient populations. The Center studies ADHD, substance abuse, Alzheimer’s disease, and depression.

Center for Imaging and Neuroscience The Center has established a state-of-the-art imaging center and is working on positron emission tomography (PET), magnetic resonance imaging (MRI), and single photon emission computed tomography (SPECT). Researchers are investigating the synergistic uses of multiple imaging modalities in studies of the human and animal brain.

Bioterrorism BNL is adapting an air pollution sensor for use in the quick identification of deadly airborne pathogens. Researchers have been using a sensitive spectrometer to “sniff” the air over a city for tell-tale 204 Federal Activities in Telemedicine, Telehealth, and Health Technology

signatures of chemical pollutants and greenhouse gases. The spectrometer records the masses of the resulting ions, producing a pattern of peaks on a graph that serves as a fingerprint of the specific pathogen being examined. The device called a laser ablation time-of-flight mass spectrometer is sensitive enough to detect a single spore of anthrax in one cubic centimeter of air in one second.

Medical Synchrotron BNL has designed a medical synchrotron capable of delivering precision doses of proton radiation to cancerous tumors producing minimal damage to surrounding health tissues. Proton therapy is considered surgery without a knife because proton beams can deliver cell killing energy with extreme precision unlike conventional x-ray radiation therapy. Using smaller beams to deliver radiation with increased precision, could have a significant impact on shortening the duration treatment and be less costly. BNL is looking for industrial partners to help build the first specialized high tech items, however, since most of an accelerator is made from conventional technology, BNL is looking for most of the work to be done by industry.

Pacific Northwest National Laboratory http://www.pnl.gov Center for Basic Proteomics PNNL awarded a five year grant from NIH supports a center for basic proteomics to research complex protein sets that allow human cells to function. Understanding the way cells work at the molecular level will lead to earlier detection of diseases and more effective treatments. One project at the University of California (San Francisco) is looking at the progression of proteomes as breast cancer develops. The funding is also developing computer and biology information systems to analyze and help understand data produced in the proteomics research center.

Liver Disease Detection Researchers at the laboratory are developing new technology to find blood proteins that spot the earliest signs of chronic liver disease. If the research is successful, the hope is to use the technology to do the same for many other diseases and make it commercially available for broad clinical use. DOE and the University of Washington are developing a new proteomics technology to search for biomarkers for liver disease.

Virtual Lung PNNL is leading a $10 million five year NIH study to devise 3D imaging and computational models to show unsurpassed detail of the respiratory systems in humans and other mammals. The grant funding helps the laboratory and partners devise imaging and simulation techniques to give a better understanding of airborne contaminants in the respiratory system, and to help improve treatments for asthma and other respiratory ailments. The research is developing a web-based model for researchers and clinicians.

Home Rehabilitation PNNL is testing a computer program to reduce difficulties associated with spinal cord injuries by 205 Federal Activities in Telemedicine, Telehealth, and Health Technology

providing at-home rehabilitation assistance. The Rehabilitation Learning Center provides training and reference materials for patients working from a personal computer. The materials have information on the types of spinal cord injuries to information on lifestyle changes that are needed, to giving video instructions on correctly moving from a wheelchair to a bed.

Electric Nose The laboratory is studying how electronic noses can be used to automatically identify volatile chemicals. An electronic nose is generally composed of a chemical sensing system (sensor array or spectrometer) and a pattern recognition system (artificial neural network). Electronic or artificial noses also have several potential applications to telemedicine. An electronic nose could function as a telesmell component of a telepresent surgical system and could identify odors in a remote surgical environment. These identified odors would then be electronically transmitted to another site where an odor generation system would recreate them. Since the sense of smell can be an important sense to the surgeon, telesmell would enhance telepresent surgery.

Research The laboratory has developed a computer tool called ScalaBLAST to analyze biological data into manageable fragments so large data sets can run on many processors simultaneously, and analysis of an organism can be done in minutes rather than weeks. The tool is used to process complex genomic sequences and is able to manage large amounts of data.

Joint Institute for Nanoscience and Nanotechnology The University of Washington and PNNL have formed the Joint Institute for Nanoscience and Nanotechnology, to research new materials and extremely small machines by manipulating individual atoms or molecules. This field will improve computer chips so that trillions of bits of information will be stored in an area the size of a pin’s head, and be able to produce biological compatible devices to be able to attack diseases at the sub-cellular level.

Life Sciences The program is working on developing leading edge tools and equipment to look at the molecular and cellular level inside organisms.

Imaging The Medical Ultrasound 3D and Portable with Advanced Communications (MUSTPAC-3) telemedicine system allows for the capture and transmittal of 3-D ultrasound images. Pregnant women living on a South Dakota Indian reservation are using the system, and the system is used at clinics operated by the Indian Health Service.

Bioterrorism Researchers are tackling bioterrorism one protein at a time. Because biological pathogens grow and spread inside the human body on a molecular level, investigators are trying to understand how pathogens 206 Federal Activities in Telemedicine, Telehealth, and Health Technology

work one protein at a time to gain the knowledge needed to develop ways to treat and protect against bioterror agents.

Ames Laboratory http://www.ameslab.gov Iowa State University operates Ames Laboratory for the Department of Energy. The Office of Biological Environmental Research funds research to help solve health problems in the U.S.

Biosensor Technology Scientists at the laboratory in collaboration with the University of Michigan have developed a novel fluorescence-based chemical sensor that is more compact, versatile, and less expensive than existing technology of its kind. The sensor holds promise for potential applications, such as monitoring oxygen, inorganic gases, volatile organic compounds, biochemical compounds and biological organisms. The sensor can be used for point-of-care medical testing, high throughput drug discovery, and detection of pathogens and other warfare agents. Scientists are developing a means for the detection of certain DNA adducts that can be found in urine. This newly developed biosensor chip technique is simpler and potentially more practical than previously developed methods. With this biosensor chip technology, scientists are able to test for the presence of a certain adduct in a sample of urine by simply dipping a chip containing the corresponding antibody into processed urine. Adducts bind to the antibody and flouoresce when scanned with a laser beam at low temperatures. The data gathered from the laser scanning can be used to produce a detailed fingerprint for adduct identification, providing vital information for cancer risk assessment.

Idaho National Laboratory http://www.inl.gov The Idaho National Laboratory developed Change Detection System (CDS) technology to highlight slight differences between digital images. The CDS software combines the strengths of rote computer analysis with the powerful human reflex elicited by flip-flop analysis, and can align images to within a fraction of a pixel from hand-held digital cameras. The alignment compensates for modest differences in camera angle, height, zoom, or other distractions that previously confounded flip-flop comparisons. The technology detects early stages of disease in medical scans.

207 Federal Activities in Telemedicine, Telehealth, and Health Technology

Department of Justice http://www.usdoj.gov

Bureau of Prisons http://www.bop.gov The Bureau of Prisons (BOP) within the Department of Justice is required to provide suitable medical care to inmates. The Health Services Division at the Department of Justice has overall direction for the BOP health care program. Costs are rising for services because the inmate population is growing and aging, inflation is occurring in the medical services industry, there is an increase in the number of inmates with drug related conditions, and there is an increase in the number of incoming inmates needing immediate medical treatment. According to a Bureau of Justice Statistics report, medical problems can also include physical impairment or mental conditions, injuries after admission, and medical problems that increase with time spent in prison especially among older inmates. The Health Programs Branch coordinates the Bureau of Prisons medical, dental, and mental health services to federal inmates. The Health Programs Branch uses a system-wide approach to providing telemedicine, telehealth consults, electronic health records, primary care provider teams, and utilization review. Medical referral centers also provide continuing professional education programs to other BOP institutions through the telehealth network. The Bureau has found that an ideal or model telemedicine system—one with all the “bells and whistles” is not necessary to realize significant cost savings. A simple video teleconferencing system with a close-up camera is adequate for many telemedicine consultations. The conclusion was that telemedical consultations were effective in some specialties such as psychiatry and dermatology, since some trips to local specialists were avoided. Also a number of transfers by air charter to a Federal Medical Center were avoided, and prisons generally were calmer with fewer incidents of violence because of the improved psychiatric care available. Other state programs are in effect with active prison telemedicine programs. For instance, in Cali- fornia, one project connects the staff at the Pelican Bay Correction Facility with the California Medical Facility where inmates are treated for psychiatric problems. According to the Bureau of Justice Statistics, 89 percent of state adult correctional facilities provide mental health services for prisoners. Almost 70 percent of the state adult correctional facilities screen inmates at intake for mental illness. Other states have active programs that are connected to state universities and state correction facilities. These states have found that telemedicine reduces inmate transportation costs, reduces security risks, increases efficiency through block scheduling of consults, increases the effectiveness of patient record tracking, and reduces public visibility of inmates.

Medication Orders Most BOP pharmacists fill medication orders directly from the patient’s chart and all pharmacists provide patient counseling. The pharmacy program is helping monitor drugs, manage diseases, and improve quality. The pharmacy system operates with multi-disciplinary clinical care teams and provides information and education to all prisoners. 208 Federal Activities in Telemedicine, Telehealth, and Health Technology

Bureau of Justice Assistance http://www.ojp.usdoj.gov The Prescription Drug Monitoring Program (PDMP) administered by the Bureau of Justice Assis- tance collects and analyzes controlled substance prescription data by using a centralized database. These programs are designed to prevent and detect the diversion and abuse of pharmaceutically controlled substances particularly at the retail level where no automated information collection system exists. The analysis of collected data also allows for the identification of outmoded prescribing practices, such as the under treatment of pain, which may result in the need to develop educational programs for medical professionals.

Office of Justice Programs The Office of Justice Programs recognizes that states, local, and tribal governments need to develop information-sharing architectures, and uses grant funds to form partnerships in support of justice information sharing. OJP has created the Information Technology Executive Council to work on funding and technical assistance in this area. The OJP’s Information Technology Initiative is studying justice information privacy.

OJP Justice Integration http://www.ojp.usdoj.gov OJP Justice Integration enables government to access and obtain timely and useful information on integration processes, initiatives, and on new policy and technology developments. The program funds states, system descriptions and overviews, telecommunications approaches, and wireless initiatives.

Illegal e-Pharmacy Internet Sites The Department of Justice stops illegal e-pharmacy internet sites. The Department of Justice en- forces numerous consumer protection statutes and can proceed with civil enforcement action along with the Federal Trade Commission. The DOJ works with the Federal mail and wire fraud statutes whenever an online or other pharmacy defrauds consumers.

Initiatives • Legislation was signed to end the operation of rogue online pharmacies that sell controlled substances and pharmaceutical medicines. The law requires a health professional to examine a patient in person for a prescription to be valid • The DOJ working with DEA, FBI, and FDA have jointly filed several cases in court and FDA’s Office of Criminal Investigations and DEA work together on criminal investigations • The White House Office of National Drug Control Policy works with DEA and state officials to expand the Prescription Monitoring Program to facilitate information sharing among jurisdictions. • The FBI and the National White Collar Crime Center have created the Internet Fraud Complaint Center. The Center has a hot line that consumers can call with web site complaint 209 Federal Activities in Telemedicine, Telehealth, and Health Technology

• DOJ conducts seminars an internet fraud with seminars on crime and electronic evidence with representatives from DOJ, DEA, FBI, FDA, U.S Customs Service, the Postal Inspec- tion Service, DOD, and other associations • DOJ works with the Council of Europe to allow law enforcement to investigate and prosecute computer and internet crimes. • DOJ works with US financial institutions to reduce the flow of money to foreign web sites to stop the use of credit card orders for the sale of controlled substance or prescription drugs.

Drug Enforcement Administration http://www.dea.gov Controlled Substances DEA has proposed a rule to allow electronic prescribing of medications classified as controlled substances. The rule includes security requirements and would apply to Schedule II, Schedule IV and Schedule V medications. The Controlled Substance Ordering System helps prevent certain pharmaceutical drugs from being used illegally and ensures that a sufficient supply is available for legitimate uses. Every time a controlled substance or schedule II substance is ordered by a physician, forms have to be completed and sent to each party. A third copy is maintained at DEA. DEA estimates that 15 percent to 20 percent of the prescriptions filled are for Schedule II drugs cost $40 per transaction. An electronic transaction for the same controlled substances would cost approximately $9 per transaction.

Computer System to Track Deaths DEA is using a computer database to enable agents to track down reports on deaths from local medical examiners and toxicologists. The system called the National Drug Related Death Reporting System is being tested in Maryland, Kentucky, West Virginia, Florida, St. Louis, New York, California, Michigan, and Washington D.C.

210 Federal Activities in Telemedicine, Telehealth, and Health Technology

Department of the Interior http://www.doi.gov

U.S. Geological Survey Center for Biological Informatics http://biology.usgs.gov/cbi The Center for Biological Informatics (CBI) develops, identifies, and provides access to tools that collect and use biological information and data. The Center cooperates with others to improve access to existing information and data that is not housed at the Center. Center activities are conducted with four teams who work together on projects and program issues that have to do with geospatial technologies, informatics research, and development program. The program investigates, designs, and applies procedures, software applications, tools, and technologies to aid in the integration of biological data. The goal is to improve the content of the National Biological Information Infrastructure and other biological information systems, by doing collection management, developing models and analytical tools, providing data on technical infrastructure, and managing information.

211 Federal Activities in Telemedicine, Telehealth, and Health Technology

Department of Education http://www.ed.gov Statewide Longitudinal Data System The 2009 recovery stimulus package provided $250 million for grants to design and develop and implement Statewide Longitudinal Data Systems. A Funding Opportunity Announcement was published in the Federal Register in July 2009.

National Institute on Disability and Rehabilitation Research http://www.ed.gov/about/offices/list/oser/nidrr/index.html The U.S. Department of Education’s Office of Special Education and Rehabilitative Services through the National Institute on Disability and Rehabilitation Research (NIDRR) coordinates research programs and related activities to maximize social integration, and helps disabled individuals use assistive technologies. NIDRR supports medical rehabilitation research responsive to the changing needs of disabled individuals. Medical advancements in the rehabilitation field have created new technology to meet the needs of the disabled, and enables individuals with spinal cord injuries to live better and more productive lives with fewer illnesses. NIDRR is using electronic media and telecommunications to reach the disabled community by:

• Developing an online disability news service, to focus on government funded research, funding opportunities, legislative information, and current issues • Exploring communications strategies for effective internet searches for disability related information • Providing technical assistance and training on the use of electronic information sites

The Department has appointed a steering committee to assist NIDRR in developing a plan for disability and rehabilitation research for the next five years. This plan is to implement an initiative to help the disabled have increased access to assistive technology and to emphasize using technology for access and function. Additional emphasis will be given to the application of technology to improve access to health care. NIDRR administers the Assistive Technology Act to provide grants to states to increase access availability, provide funding for assistive technology, and help states provide services to rural and under represented populations. The states are able to provide legal advocacy to disabled individuals in regard to assistive technology issues. NIDRR programs are focusing more on telerehabilitation and working to increase services offered to people in rural or underserved areas.

Rehabilitation Engineering Research Centers http://www.ed.gov/programs/rerc/index.html NIDRR’s research is conducted through a network of individual research projects and through the Centers of Excellence located throughout the country. Most NIDRR grantees are universities or providers of rehabilitation or related services. NIDRR’s largest funding programs are the Rehabilitation Research and Training Centers (RRTCs) and the Rehabilitation Engineering Research Centers (RERCs). 212 Federal Activities in Telemedicine, Telehealth, and Health Technology

The RRTCs provide information and technical assistance resources to providers, individuals with disabilities, and others by giving workshops, conferences, and public education programs. The RERC’s disseminate innovative advanced technology at the individual level, to lessen the effects of sensory loss, mobility impairment, chronic pain, and communication difficulties. The NIDRR program supports the Mobile Wireless Rehabilitation Engineering Research Center (RERC) and develops mobile wireless technologies for persons with disabilities. The RERC a five year program is funded by NIDRR and led by the Georgia Centers for Advanced Telecommunications Tech- nology, Shepherd Center, and the Georgia Institute of Technology. The aim is to provide equitable access to mobile wireless products and services and investigate promising applications of mobile wireless technologies. Development activities include using universal control and multimodel interfaces for mobile wireless devices, developing wearable captioning devices, providing mobile wireless communication access along with telerehabilitation and telehealth, and providing wireless technology to use with cognitive prosthetics. Each development project involves building a prototype, soliciting feedback from consumer advisory groups, and refining promising concepts. The Minnesota Telerehab Initiative funded by the RERC Telerehabilitation program provides specialty rehabilitation service to hospitals, clinics and practices in underserved rural communities. The funding provides direct patient care to individuals in their homes, provides appropriate video conferencing technology options, expanded telerehabilitation services to the Leech Lake Indian Reservation, and provides continuing education to rehabilitation professionals using video conferencing technology.

Office of Special Education and Rehabilitative Services http://www.ed.gov/about/offices/list/osers/index.html The Office’s program called “Technology and Media Services for Individuals with Disabilities” improves results for children with disabilities by developing and demonstrating technology. The technologies may include, but are not limited to technology-based assessments, computer-adaptive testing, computerized curriculum-bases measurement, and technology based instruction.

Migrant Student Information The Migrant Education Program is a state-operative grant program where funds are used to help migratory children. The program requires the states to transfer migrant student records to help migratory children improve their schooling. These records must contain their educational information but also their health records in order for the states to receive grants.

SBIR Program http://www.ed.gov/programs/sbir/links_agency.html The NIDRR SBIR program priority areas are to provide access, promote integration, foster independence of individuals with disabilities in the community, workplace or educational setting, and enhance sensory or motor function of individuals with disabilities. The SBIR program encourages projects in artificial intelligence, information technology devices, software systems, and product design. The research needs to help in the exchange of expertise, provide information and training, and help the disabled and individuals undergoing rehabilitation. 213 Federal Activities in Telemedicine, Telehealth, and Health Technology

Department of Labor http://www.dol.gov The Department’s Employment & Training Administration has $220 million in grant funds available through stimulus funding to use to train and help workers pursue careers in healthcare and other high growth and emerging industry sectors. ETA is providing $125 million of the designated funds for healthcare projects, and funding 45-65 grants ranging from $2 million to $5 million. DOL also intends to use a portion of the funds to create a virtual tool to help workers learn about and prepare for careers in healthcare. The Department of Labor awarded grants to four rural hospitals in southwestern Minnesota to train entry level workers for jobs as registered nurses. The grants help hospitals and distant colleges use computer cameras and televisions to educate, and eventually 20 virtual classrooms in the state will be funded. The grants provide funding to help nurses earn master’s degrees. The project increases the number of nurses in rural communities, educates, and recruits nurses. By using distance education, rural colleges have a universal list where students are able to take classes all year regardless of location and scheduling. The Employment and Training Administration within the Department of Labor funds and oversees programs to provide work experience and training for groups having difficulty entering or returning to the work force, and retrain the nursing profession. 214 Federal Activities in Telemedicine, Telehealth, and Health Technology

Department of State http://www.state.gov

Bureau of Oceans and International Environmental and Scientific Affairs http://www.state.gov/g/oes Office of Space and Advanced Technology The Bureau sponsors two telemedicine projects in Afghanistan and in Pakistan. In Afghanistan, hospital infrastructure is weak in remote rural areas, and 50 of the nation’s 330 districts lack basic medical or health facilities. The country has a mountainous terrain, poor transportation networks, and a weak education infrastructure that makes it hard to upgrade health care because educating doctors and building more health clinics is very difficult. The project in Afghanistan is collaborating with India and the U.S. to establish a network of stations in remote areas to be used for telemedicine consultations. Each remote station will use satellite communications networks to communicate. An Afghan team consisting of physicians and IT specialists operate the equipment at Kabul’s Indira Gandhi Hospital. The second phase of the project will use the knowledge gained from the first project to design a telemedicine program for Afghanistan. The second project in Pakistan supports a telemedicine training center at the Holy Family Hospital in Rawalpindi, Pakistan. For the project, two Pakistani doctors visited the U.S.Army’s Medical Research and Material Command to study how telemedicine works and to establish contacts in their country. Experts from the MRMC and the Medical Informatics and Technology Applications Consortium at Virginia Commonwealth University provided telemedicine training to the Pakistani medical specialists. As a result, a public private partnership was established by the State Department and DOD to use telemedicine to help broaden and strengthen technical capabilities supporting the “hub” Holy Family Hospital. In addition to starting the project, the U.S has contributed $220,000 to purchase state-of-the-art telemedicine equipment and services to operate the project. The project has already expanded medical care to hundreds of patients, preoperative planning and follow-up, cardiac assessment, ophthalmology, dermatology, radiology, infectious disease, perinatal evaluations, and medical triage for traumas and acute illness.

Office of International Health Affairs IHA promotes global health by encouraging strong leadership on health policy and works with many other public agencies and the private sector on bioterrorism, health security, environmental health, infectious diseases, and surveillance and response.

Partnership with the Department of Defense The Department of State and the Defense Department are working on a pilot project to determine if the AHLTA electronic system used by DOD is a feasible system for the State Department to adopt. The State department is looking at AHLTA over other electronic medical records because of proven reliability in remote and austere environments and the fact that the system is in compliance with tough DOD security standards. The State Department anticipates that AHLTA will eventually be used to support State beneficiaries abroad, since many beneficiaries seek treatment at both State and Defense facilities. 215 Federal Activities in Telemedicine, Telehealth, and Health Technology

Department of Transportation http://www.dot.gov The National Highway Traffic Safety Administration within the Department of Transportation holds Federal Interagency Committee meetings concerning emergency Medical Services. Legislation passed and referred to as the Safe, Accountable, Flexible, and Efficient Transportation Equity Act: A Legacy for Users (SAFETEA-LU). The legislation provides for the Committee to work with HRSA, the Direc- tor of the Preparedness Division within the Directorate of Emergency Preparedness and Response at the Department of Homeland Security, as well as with state emergency medical services directors on issues pertaining to the requirements of SAFETEA-LU and other issues involving emergency medical services. New regulations are proposed for the E-911 grant program. The new Emergency Technologies 911 Improvement Act of 2008 amends the ENHANCE 911 Act of 2004 to permit grant funds to be used for migration to an IP enabled emergency network. 216 Federal Activities in Telemedicine, Telehealth, and Health Technology

INDEPENDENT AGENCIES AND COMMISSIONS National Aeronautics and Space Administration http://www.nasa.gov NASA monitors the medical conditions of astronauts in space and relays this information to earth. In recent years, due to terrorism, and the budget needed for defense spending, along with disaster relief, NASA has not been as active in developing technology as in previous years. However, ARRA provided $400,000 for NASA’s science program to spur technological advances in science and health. Funding for monitoring technology would make it possible for NASA to continue to adapt telecommunications and healthcare technology for human space flight, and continue to work on developing cost-effective applications for integrated healthcare technology.

NASA Specialized Centers of Research NSCOR supports the Space Radiation Program Element within the Human Research program. The agency is funding collaborative research with four institutions in New York, Texas, California, and the District of Columbia to understand space radiation carcinogenesis and central nervous system risks.

Heart Monitoring Systems Engineers have developed the Crew Physiological Observation Device (CPOD) to report on the health of an astronaut from space. The device records information continuously using multiple sensors and transmits this data in real-time to physicians. Since the device is small, astronauts can be monitored without restricting movements. The Glenn Research Center in Cleveland Ohio is developing a heart monitoring system with advanced EKG capabilities. MetroHealth Medical Center in Cleveland in collaboration with NASA has been able to amplify astronaut’s heart patterns and detect arrhythmias or slight changes in the heart’s rhythm during exercise stress tests. The device incorporates NASA’s Embedded Web Technology, where a miniature server records the EKGs and sends the information over the internet. Researchers are doing clinical tests on the ground version of the system which includes a global positioning system to track the patient’s location.

Ultrasound Techniques X-ray and computerized tomography scans are routinely used by doctors to diagnose medical conditions on Earth but they are not available on the International Space Station due to weight and power requirements. NASA has developed a 168 pound ultrasound machine ready for testing on the Space Sta- tion. The equipment is capable of high resolution imaging for a wide range of applications and is able to transmit images by satellite to the ground where radiologists can read the images.

Applied Sciences Program Satellite systems are being used to gather data so that outbreaks of infectious diseases such as malaria, West Nile virus, and other plagues can be predicted and prevented. The system gathers data on 217 Federal Activities in Telemedicine, Telehealth, and Health Technology

rainfall, the effect on vegetation, and topography from the satellites. This data can predict diseased spread by many insects and rodents. The data is than sent to CDC, DOD, state health agencies, WHO, and many foreign governments.

Electronic Health Systems NASA has investigated using several electronic health record systems and found that the Indian Health Service Resource and Patient Management System (RPMS) based upon VHA’s VistA system is closest to NASA’s requirements. NASA and IHS are working to develop an occupational health module to integrate with the RPMS. The system will be secure, provide a central data warehouse, and provide alerts and advisories. The Patient Safety Reporting System (PSRS), a NASA and VA collaboration operated by NASA, receives patient safety reports from VA medical facilities to allow NASA PSRS office to study the findings. The NASA PSRS issues Patient Safety Bulletins to identify significant vulnerabilities however; they do not identify a specific solution that must be implemented.

Underwater Research The crew of the NASA Extreme Environment Mission Operations (NEEMO) 9 mission spent 18 days underwater living aboard Aquarius, an undersea laboratory stationed 67 feet down just off of Key Largo in the Florida Keys. Many undersea moonwalks were accomplished, and the key goal was to assemble and operate a surgical robot with cameras and dexterous pincers designed to allow doctors to dress wounds remotely with only an internet link-up between them. In one experiment, NASA sent a flight surgeon, two astronauts, and a doctor into the ocean depths off the Florida coast aboard the Aquarius to test space medicine concepts. The mission practiced hands- on telesurgery demonstrations and robotic telesurgury so that surgeons in the future will be able to overcome interplanetary communication lag times.

Office of Biological and Physical Research http://exploration.nasa.gov NASA’s Office of Biological and Physical Research (OBPR) perform basic and applied research to support human exploration of space. The cross-disciplinary research programs bring physics, biology, and chemistry together with a wide range of engineering disciplines. OBPR includes programs in physical sciences research, space biology research, biomedical and human support research, bimolecular physics and chemistry, biotechnology, earth-based applications, microgravity research, radiation research, and space product development. OBPR conducts research activities with NIH, NSF, DOD (including DARPA, Air Force, Office of Naval Research), and the Department of Energy through 40 partner agreements. OBPR also manages 12 Commercial Space Centers across the country. OBPR researchers are involved in a number of projects such as:

• Studying growth patterns in microscopic crystals to lead to improved manufacturing for pharmaceuticals and other materials • Studying how to improve cochlear implants by working microelectronics, wireless communications, and microelectromechanical systems 218 Federal Activities in Telemedicine, Telehealth, and Health Technology

• Doing research on the human brain to see if the nervous system contains a hardwired model of gravity. • Doing bioastronautics research to develop therapeutics, procedures, techniques, and equipment needed to address flight medical safety. • Studying how to use microgravity to effectively better understand the fundamental biological processes and looking at the effects of microgravity on bone as a function of age.

Health and Medical Office http://ohp.nasa.gov/ochamo The Health and Medical Office oversees and advises on health and medical care for space crews in training and flight and oversees requirements for clinical care and medical research for the protection of human research subjects and patients. NASA has developed the Portable Medical Status and Treatment System designed to use in remote areas. The battery-powered system includes a vital signs monitor and defibrillator, which delivers electrical shock to the patient and transmits vital signs to a distantly located physician. As the Centers transition to electronic health record systems, the Office of the Chief Health and Medical Officer will coordinate training opportunities \ Occupational Health Program The program is working to standardize health data collection by instituting and evaluating an agency wide Health Risk Assessment instrument. The decision was made to pilot the Mayo Clinic Embody Health Initiative and use the Mayo HRA tool.

Aerospace Technology Program NASA’s Aerospace Technology program emphasizes Computing Information and Communication Technology (CICT), and does research in biotechnology, nanotechnology and intelligent systems. The nanotechnology and biologically inspired technologies will be integrated into the traditional aerospace sciences. NASA’s goal is to commercialize all technologies created at NASA centers, as well as innovations produced by NASA contractors.

National Space Biomedical Research Institute http://www.nsbri.org NASA with the Johnson Space Center and the Baylor College of Medicine in Houston Texas has established the National Space Biomedical Research Institute to conduct focused biomedical research necessary to support human health in the exploration and development of space. NSBRI’s consortium members include Baylor College of Medicine, Harvard Medical School, Johns Hopkins University, MIT, Morehouse School of Medicine, Rice University, Texas A&M University, University of Arkansas for Medical Sciences, University of Pennsylvania Health System and the University of Washington. The Johnson Space Center in Houston Texas sponsors the Institute. Research is ongoing on bone loss, response to chronic stress and fatigue both in space and underwater, cardiovascular alterations, muscle changes, balance problems, radiation effects, technology devel- 219 Federal Activities in Telemedicine, Telehealth, and Health Technology opment, physical fitness and rehabilitation, smart medical systems, and nanotechnologies. NSBRI along with researchers at the University of Cincinnati are developing a system for monitoring multiple oxygen use for individuals during transport. The study uses an autonomous module that can change settings breath to breath based on the individual’s needs. This smart system will help to maintain an adequate oxygen supply to the body as well as net oxygen conservation. In another project, NSBRI is funding the development of a sensor and portable monitor for astronauts to use in space. The futuristic system dubbed the “Vensus” prototype is a noninvasive monitoring system to help NASA astronauts know how much oxygen they are using up in space. NSBRI is studying the effects of lunar dust on the human body. This is important since in the future, man may spend much more time on the moon. Lungs are highly sensitive because of the large surface area that delivers oxygen molecules through a thin membrane directly to the blood. The health risk to astronauts increases as dust particles go deeper into the lungs. The Smart Medical Systems Team within NSBRI is studying the High Intensity Focused Ultrasound (HIFU) device with the Department of Defense. Using diagnostic ultrasound to image a problem area, tumor site, or internal trauma injury, an individual will then be able to point-and-shoot the HIFU transducer and destroy unwanted tissue along with cauterizing a lesion or blood vessel. NSBRI has developed a patient simulator to train for medical emergencies in space. The simulator breathes, has a heartbeat, pupils that react to light and medications, a pulse that can be felt at five locations and lung sounds. About 200 parameters can be changed so that any type of patient can be created along with simulated medical events that could happen. The simulator is linked to a computer that controls the patient’s reactions and can be programmed to mimic various situations. For example, in a session on allergic reactions to medications, participants face a wheezing simulator with a rapid pulse and swollen tongue.

Other Projects with Universities Several ongoing projects with universities:

• NASA is working with MIT on growing heart tissue using NASA bioreactor technology, to grow tissues in the laboratory to help reproduce the properties of natural tissues in the body • NASA along with other major health organizations and the University of Pittsburgh have developed a Global Health Network. This project provides access to data on a variety of medical and global health issues, and serves as a virtual university. • Researchers at the University of Texas at El Paso have formed a partnership with NASA to adapt telemedicine equipment used on space missions to be used in underserved Texas communities. UTEP researchers are working on ways to make the Telemedicine Instru- mentation Packages smaller and more efficient. Beaumont Army Medical Center also participates in the project and uses one of the telemedicine packages at its clinic

International Activities NASA has been working with several countries:

• NASA worked with Pakistan in an earthquake with U.S. physicians to communicating with Pakistan on medical issues. The program provided distance learning for medical 220 Federal Activities in Telemedicine, Telehealth, and Health Technology

students so that these students were able to diagnose injuries and communicate to local health care workers • NASA established telemedicine links between Star City, Russia and Houston, Texas to communicate with U.S. and Russian doctors, astronauts, and their families • NASA is studying the Rainforest from space and has brought telemedicine capabilities to regions of the Andes. A mobile surgery clinic operated by the Cinterandes Foundation in Cuenca, Ecuador, and a team of NASA and university researchers provided surgical care to remote villages by using interactive consultations for patients deep in the Andes and rainforest

International Space Station The International Space Station (ISS) is a NASA partnership with the Russian Agency, the Canadian Space Agency, the European Space Agency, and the Space Agency of Japan. To support medical risks during the operation of the ISS, NASA has developed a Crew Health Care System to support in flight medical care. Flight surgeons and crewmembers can be in constant contact with the Control Center in Houston and with medical personnel in their home country. NASA has done biomedical experiments on space crews in radiation dosimetry, psychosocial factors, sleep physiology, and sensorimotor coordination. ISS is used as a testbed for updating technologies with miniature portable equipment on board. Biosensors on the ISS provide environmental monitoring along with abilities to diagnose health problems. In the future, ISS will study diagnostic and life support capabilities as well as deliver targeted therapies to the site of injury, decision support systems, and computer-based medical training, along with access to holographic 3D imaging. Also, in the future, genetic and DNA therapies could offer detection, diagnosis, analysis, and treatment for many illnesses while in space for long periods of time, and biologically inspired technologies, miniaturization, nanotechnology, and information systems could be combined used in space. The Space Station is using microgravity as a research tool to gain new knowledge. More than 40 biomedical research experiments have been scheduled and space science will also be conducted remotely by a team of controllers and scientist on the ground. Research areas include healthcare, space physiology and radiation, and environmental health instrumentation and monitoring

Telemedicine Instrumentation Pack While in orbit, NASA uses the Telemedicine Instrumentation Pack (TIP). The pack uses modern telecommunications systems, medical instruments, and computers to provide specialty consultations and links to ground controllers. The Pack has an integrated suite of tools and utilities to conduct telemedical exams that include eye, ear, nose, throat, and skin imaging, EKG, and blood oxygen saturation monitoring, and heart and lung sounds monitoring. TIP’s medical imaging instrumentation includes a common CCD video camera, a full color flat panel video LCD display, and a halogen light source. Each package fits into a small metal suitcase.

Collaborative Activities NASA and NIH have signed an agreement to help American scientists do research on the Interna- tional Space Station to answer questions about human health and diseases. Weightlessness will be studied 221 Federal Activities in Telemedicine, Telehealth, and Health Technology

to help deal with fragile bones, effects on the brain, and changes in microbe infectivity. In 2009, it was announced that the two agencies are ready to find ways to do the research but the awards available for the program are dependent on funding availability. NASA and the National Cancer Institute have signed an agreement to develop new biomedical technologies and sensors to detect, diagnose, and treat diseases on earth and in space. NCI is collaborating with NASA’s ORBR to develop minimally invasive microscopic sensors to advance and support health monitoring and patient care. NASA and NCI are working on the detection and diagnosis of disease and spaceflight induced physiological degeneration. Discoveries from this program hopefully will complement and link efforts supported through the NCI Unconventional Innovations Program (UIP) and NASA’s Biomolecular Systems Research. NASA and the Uniformed Services University of Health Science (USUHS) are using teleconferencing to link 14 NASA centers with five institutions across the globe. The network provides information to physicians and nurses so that they can continue accredited education. The Virtual Collaborative Clinic is a joint effort between NASA’s Glenn Research Center, Stan- ford University, Salinas Valley Memorial Hospital, Northern Navajo Medical Center, and NASA’s Ames Research Center. Physicians at remote sites are able to work together using a high-speed system to plan difficult surgeries.

Biomolecular Systems Research NASA’s Biomolecular Systems Research Program brings together biology, physics, and chemistry with a wide range of engineering disciplines and information technologies. In the future, this program will develop breakthrough technologies and deliver prototype biomolecular micro and nanosystems to support NASA’s scientific and medical objectives for extended duration space flight, life detection, and planetary protection.

Space Centers Ames Research Center http://www.arc.nasa.gov Research Activities NASA’s Ames Research Center studies advanced biosensors and biotelemetry systems and technologies for space life sciences and telemedicine. Sensors and related devices are used at the University of California at their San Francisco Fetal Treatment Center. Researchers have developed a miniaturized implantable Fetal Health Monitoring system to help reduce post-natal health care costs. The Biocomputation Center at the Ames Research Center is collaborating with craniofacial surgeons at Stanford University Medical Center to develop a virtual environment workbench to help plan complex craniofacial reconstructive surgery and to train new surgeons. Ames Research Center’s Autogenic Feedback Training Exercise (AFTE) system has compact ambulatory equipment to measure, record, and display real-time ANS functions. The astronaut wears a garment that can measure and wirelessly transfer physiologic data in real-time, along with a small wrist display. A 222 Federal Activities in Telemedicine, Telehealth, and Health Technology

trainer sits at a computer station to capture and monitor the data. The data is used to work with individuals on developing regulation techniques to prevent motion sickness. The Ames Astrobionics and the Stanford National Biocomputation Center are working together on a system called “Life Guard”. The system is unobtrusive, easy to use, able to log vital signs, transmits vital signs in real-time, and is applicable to clinical and home health monitoring as well as first responder and military applications. The core component of the system is a small, lightweight, wearable device called CPOD that is worn on the body along with several sensors attached. The sensors measure vital signs with the device recording physiological parameters up to eight hours and can download or stream these parameters in real-time to a base station PC on demand. Ames and the Salinas Valley Memorial Hospital are working together to advance future medical imaging technologies in animals and human models. The researchers are developing non-invasive ways to analyze humans and animals.

Jet Propulsion Laboratory http://www.jpl.nasa.gov Virtual Medical Center JPL operating under contract to the California Institute of Technology in Pasadena California has developed a web-based NASA Virtual Medical Center (VMC) to allow physicians from all over the world to collaborate with each other. A remote physician can register patients into the VMC, interact with remote physicians through a cross platform electronic whiteboard, access patient radiological images and pathology images on line, and perform real-time image renderings.

Vision Research The laboratory has been working on a vision test using a laptop computer with a touch sensitive screen that can be used on Earth and in space to help diagnose the onset of eye diseases and even certain types of brain tumors. With one eye covered, a person sits in front of a computer screen divided into a grid, the subject stares at a central spot on the touch sensitive screen, and using a finder, outlines missing areas of the grid. The computer records, processes, and displays a 3D image of the subject’s visual field. This procedure is a non-invasive, quick and easy process that gives astronauts and physicians on the ground an almost instant auto diagnosis.

Imaging The laboratory has developed 2-D image change detector algorithms that look at small changes in the size of tumors or other internal features. This algorithm has the advantage of pixel averaging to actually increase the resolution of the image. The laboratory has also developed a PC-based image processing system to improve visualization of new skin lesions in individuals with multiple dysplastic nevi syndrome. The system operates by matching and subtracting serial images and color coding changes in the different images and brings attention to new or enlarged nevi.

Mapping Brain Tumors Researchers at JPL have developed an infrared video camera and surgeons can look at thermal 223 Federal Activities in Telemedicine, Telehealth, and Health Technology

imaging and image processing to see if useful maps can be made of brain tumors. Researchers want to see if the camera, which detects infrared or heat emissions can help neurosurgeons better visualize tumors before they operate and also find tiny clusters of cancerous cells that might remain after surgery.

JPL Commercialization Center The JPL Commercialization Center serves as a one-stop shop for companies that want to work with JPL’s Commercial Technology Program to develop and transfer technologies for public use. The Center provides information on JPL’s capabilities, technologies, expertise, and research and development activities. Several JPL success stories are:

• JPL formed a Technology Cooperative Agreement with MicroDexterity Systems Inc. to develop a robotic microsurgery device to use for delicate surgeries. The device uses computer compensated motion control to dramatically reduce the effects of operator muscle tremor. The robotic arm can improve the accuracy of existing surgical techniques by a factor of ten. A new robotic microdexterity platform with applications to medicine has been developed, and enables new procedures to be done on the brain, eye, ear, nose, throat, face and hand. The technology was designed in cooperation with micro surgeons. • The JPL Biomedical Image Processing Laboratory with Eye Dynamics Inc. developed a method for comparing dermatological images. These images were taken over time to monitor and tract constantly changing moles that are at high risk of developing into malignant melanomas. The screening method uses sophisticated optical image warping, and a color coding system to categorize the moles photographed. Images can be compared in a matter of minutes by displaying a color coded change image that highlights moles that are new or enlarged, which appear red, and moles that have disappeared or become smaller, which appear green.

Langley Research Center http://www.larc.nasa.gov Research Activities Langley researchers have developed a new material that not only benefits the aerospace sector but also may extend the quality of live. The material “Soluble Imide” or referred to as LaRC-SI is a material that is highly flexible, resistant to chemicals, and can withstand extreme hot and cold temperatures. The material is suitable to use in medicine and this includes using the material for implantable devices. The Langley Research Center uses an x-ray detector for use in digital mammography. The detector consists of a mosaic of commercially available CCD arrays to provide digital detection in a large format array. The large field of view enables the device to be used for mammography to detect early breast cancer. The Center has worked with Baby Beats Inc., and Washington State University’s Small Business Development Center in Spokane Washington, to transfer and develop aerospace technology into a portable, non-invasive, easy-to-use fetal heart monitor. Expectant mothers with high-risk pregnancies and those that have trouble traveling to a doctor’s office are envisioned to be the primary users of the baby monitor. 224 Federal Activities in Telemedicine, Telehealth, and Health Technology

Johnson Space Center http://www.nasa.gov/centers/johnson/home/index.html Medical Monitoring in Space JSC is heavily involved in telemedicine activities, and working on experiments to see how a satellite communication link can be used in on board the space shuttle. Houston conducted an experiment at a distance location on patients, and physicians were able to make an accurate diagnosis of their ophthamol- gical conditions. GE Medical Systems Information Technologies with NASA can now monitor the cardiac health of astronauts with the astronaut’s cardiac information transmitted in real-time to Mission Control at the Johnson Space Center.

Communication and Database Technology The Advance Communications Technology Satellite (ACTS) program is program is working with medical personnel to deliver healthcare services to remote locations using more mobile communications. The Johnson Space Center is working on a demonstration project with St Vincent’s Hospital in Billings, Montana, and the Crow Indian Reservation Clinic 70 miles away from the hospital, to transmit images and information to specialists for diagnosis. Medscape an electronic medical record vendor has compiled more than 40 years of astronaut medical information into a database. With information dating back to Project Mercury in 1959, the database is part of an electronic health record system at the Johnson Space Center, and with the completion of the database, NASA will be able to analyze the effects of space travel on humans.

Learning Technologies Project The Learning Technologies team is building an array of e-tools for blind or low vision students, educators, and professionals. The Information Accessibility Lab is a software platform to provide an alternative way to access NASA math and science content, which would otherwise require graphical display that would be unseen by the visually impaired.

International Activities In a test project, NASA provided telecommunications and medical imaging linkups so that a University of Mississippi physician was able to direct interventional image guided surgeries. The doctor was in Jackson MS, while the patients were in two hospitals in Japan. The Johnson Space Center has a global Telemedicine Consultant Network to allow medical operations personnel located at different sites to communicate and exchange information, as well as do telemedicine consultations with medical experts located at various medical centers.

Marshall Space Flight Center http://www.msfc.nasa.gov The Marshall Space Flight Center in Huntsville Alabama has several networks. One network is the 225 Federal Activities in Telemedicine, Telehealth, and Health Technology

Statewide Health Information Network (SHINE) and the other is the West Virginia Rural Community Health Care Computerized Network System. MSFC has developed technology that allows users to improve videotape sequences and still images extracted from moving videos. The Video Image Stabilization and Registration technology (VISAR) reg- isters and enhances video images, and after registration, frames may be co-added to enhance clarity.

Glenn Research Center http://www.grc.nasa.gov The Glenn Research Center has licensed technology to Endotronix, Inc. of Peoria Illinois to help individuals avoid complications of hypertension, abdominal aortic aneurysms, and congestive heart failure. Researchers at Glenn have identified the potential to apply radio frequency technology to Bio-MEMS sensors. This technology can now be used in a non invasive way to monitor the astronauts health needs in space.

Medical Informatics and Technology Applications Consortium http://www.meditac.org MITAC, a NASA research partnership includes partners from government, academic institutions, and industry with commercial interests in products and technology related to telemedicine, medical informatics, and medical technology. Academic and medical partners include Virginia Commonwealth University, Yale University, Columbia University, Stanford University in their National Biocomputation Center, MIT, New York Presbyterian hospital for Columbia and Cornell University and the University of Maryland in their East-West Space Science Center. The MITAC program is located on the Medical Campus of the Virginia Commonwealth University. The program uses many test beds for evaluating technology while studying and evaluating models in remote environments, and is developing unique tools for broad applications in clinical consultation, education, and evidence based medicine. Through partnerships, MITAC is working on Sensors, Transmitters, Effectors and Process Simulators (STEPS) as well as exploring technologies and partnerships in the field of medical informatics.

International Activities MITAC telemedicine projects have been initiated in other countries:

• Numerous surgeries were performed in Cucua Ecuador and monitored and mentored from Virginia Commonwealth University • MITAC has worked on Mt. Everest and Haughton Crater on Devon Island in the Arctic Circle to explore wireless physiological monitoring of individuals in extreme environments. • A variety of computer controlled robots have been provided by Computer Motion to better assess surgical skills in an open surgery that was projected on standard video monitors • Developed the Telecollaboration Online Database (TOLD to serve as an electronic medical record, an interactive tool for education and distance learning, and as a clinical consultation platform. 226 Federal Activities in Telemedicine, Telehealth, and Health Technology

• Working on rapidly deployable telemedicine systems to deal with the aftermath of a natural disaster or other events that impact on a region’s medical infrastructure. • Developing equipment to monitor patients using sensors and smart systems after they have been released from the hospital. • Working with the Virginia Biotechnology Pack which serves as an incubator for fostering commercial endeavors and assisting MITAC with commercial development from bench to market.

NASA SBIR Program http://sbir.gsfc.nasa.gov NASA’s SBIR program has worked on several projects to help the medical community. One project called the Pyxis HelpMate Secure Pak transports pharmaceuticals, laboratory specimens, medical records, and radiology films throughout the hospital. Pioneer Astronautics through the SBIR program at JSC, was able to conduct comprehensive in house testing of the Nitrous Oxide-Based Oxygen Supply system. The system achieves completer nitrous oxide dissociation with minimal formation of gas. The company also has worked on several other SBIR projects.

Innovative Partnerships Program The program funds leverage technology investments, dual use technology related partnerships, and technology solutions for NASA. IPP implements NASA’s SBIR and STTR programs. IPP manages a Seed Fund to address technology needs through cost shared joint development partnerships and the Centennial Challenges Program.

NASA eNTRe http://entre.nasa.gov The web site was set up to help NASA employees and parties under NASA funding agreements such as contracts, grants, cooperative agreement, and subcontracting to report new technology information directly via a secure internet connection to NASA. 227 Federal Activities in Telemedicine, Telehealth, and Health Technology

National Science Foundation http://www.nsf.gov The National Science Foundation (NSF) supports research in all the scientific and engineering disciplines, with interests in telemedicine. The agency is especially interested in developing new technologies that will help people with disabilities. The agency received $3 billion from ARRA to increase the agency’s super computing capabilities. ARRA also allocated funding for NSF’s Major Research Instru- mentation Program and for an Academic Research Infrastructure program.

TeraGrid NSF has made a five year $148 million award to operate the TeraGrid. Researchers and educators are able to look at large amounts of data on genomes, look at medical data involving the brain, and are able to make disease diagnosis by having access to sophisticated IT applications and computational tools.

Biomedical Program The NSF biomedical program focuses on high impact transforming technologies to derive information from cells, tissues, organs, and organ systems, extract useful information from complex biomedical signals, find new approaches to designing structures and materials for eventual medical use, and develop new methods for controlling living systems.

Biomedical Engineering Program NSF scientists are applying engineering principles to problems in biology and medicine. Research is being done in genome-enabled biotechnology, biological informatics, biochips, sensors, biosensors and diagnostics. The biomedical engineering research program develops robotics and intelligent machines to assist with people with disabilities, and works on devices, technology, and materials that will impact on healthcare delivery systems and reduce costs for the disabled population. This program also supports undergraduate engineering design projects, especially those projects that provide prototype, “custom- designed” devices or software for persons with mental and physical disabilities. The NSF Biosensing Program supports innovative research in the area of monitoring and identifying technological breakthroughs existing at the intersection of engineering, life science, and information technology. The goal is to further develop devices that result from research in interdisciplinary fields with emphasis on applications to the biomedical, food safety, energy, environmental, and security needs areas.

Directorate for Biological Science http://www.nsf.gov/dir/index.jsp?org=BIO The Directorate’s Biological Databases and Informatics program studies new ways to manage, analyze, and disseminate biological knowledge, and researchers are developing informatics tools and resources that have the potential to advance all fields of biology.

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Directorate for Computer and Information Science and Engineering http://www.nsf,gov/dir/index.jsp?org=CISE The Directorate is using intelligent systems to communicate and store knowledge, focusing on advancing human language technology, robotics and human computer interactions, and embedded intelligent systems. The program helps people with medical and disability problems that can be helped by human-centered personal robotics. CISE uses an interdisciplinary approach, drawing on mathematics, computer science, engineering, along with biological behavioral and cognitive sciences. NSF funded researchers are working on a project called STIMULATE to develop systems that mimic other forms of communication that humans use to interact with each other, including eye contact, touch, and voice. Computer scientists and electrical engineers at Rutgers have designed Multimodal Input Manager Hardware that simultaneously receives speech, gaze, and tactile signals. Special software called fusion agent assimilates the complex inputs so that the computer may respond to subtle signals that humans routinely use to communicate with one another. A pneumatic “force-feedback” glove patented by Rutgers University weighs less than three ounces and reads gestures by detecting fingertip positions relative to the palm. It lets the user point at the computer screen, overriding signals from a gaze-tracking camera. Other gaze trackers require cumbersome headpieces, but the MIM’s gimbal-mounted unit sits on the desktop and rotates to detect where the user is looking. After a 10 second initial calibration of the infrared detectors, the user can direct a cursor just by looking at a section of the computer screen.

Directorate for Engineering http://www.nsf.gov/dir/index.jsp?org=ENG The Directorate for Engineering, Directorate for Mathematical and Physical Sciences, Directorate for Biological Sciences, Directorate for Geosciences, and the Office of Polar Programs are interested in sensors and sensor networks. The thrust is to develop sensors for toxic chemicals and biological agents and integrate sensors into engineered systems. Information Technology Research Program NSF is upgrading computing infrastructure to support research and engineering activities. The Cyber Infrastructure Initiative (CII) project adds hardware and software to build on the existing Partner- ship for Advanced Computational Infrastructure (PACI). The Program focuses on:

• Software, and hardware system architectures, on operating systems, programming languages, and communication networks. Research is being done on systems that acquire, store, process, transmit, and display information • Improving information storage and retrieval and how to use the vast amount of information that has been digitized and stored • Researching ways to overcome the digital divide separating the information “haves” from the “have nots” • Network applications including collaboration technologies, digital libraries, distributed computing, remote operations, and security and privacy issues • Highly automated and mixed technologies to provide human enabling physical devices and systems to help individuals with tasks or therapies and treatments. 229 Federal Activities in Telemedicine, Telehealth, and Health Technology

• Biological system informatics and genomic information, while doing data mining and data modeling

Engineering Research Centers http://www.erc.assoc.org NSF has established an Engineering Research Center (ERC) at the University of Arizona. The researchers are developing optoelectronic technologies to provide for high bandwidth and low cost widespread access networks, to deliver data more than a thousand times faster. Another center, the ERC for Biomimetic Microelectronic Systems headquartered at the Univer- sity of Southern California (LA) works with the medical device and IT industries. The Center develops enhanced microelectronic systems to enable implantable and portable devices to treat blindness, loss of neuromuscular control, paralysis and loss of cognitive function. NSF supports an ERC for Computer Integrated Surgical Systems and Technology. This Center is developing a new generation of computer integrated surgical systems to incorporate advanced imaging robotics and biomedical engineering technology to provide systems and devices to assist surgeons. NSF awarded Carnegie Mellon University and the University of Pittsburgh funding to establish ERCs to develop technologies to help older adults and people with disabilities live independently and productively. The research conducted at the Quality of life Technology Engineering Research Center will develop intelligent systems that can co-exist with and work with people particularly those with impairments. The systems can include devices that a person carries or wears or a mobile system that a person rides and can be used to monitor the health and activity levels of people.

Nanotechnology NSF works on nanotechnology activities ranging from investigation of biologically based systems that exhibit novel properties to the study of nanoscale control of the structure and composition of new materials. NSF works with other agencies to develop nanoscale science and engineering through investments in the research of individual investigators and small interdisciplinary teams. NSF has more than ten large science and technology, engineering research and materials research centers, with one center developing instrumentation and facilities for the National Nanofabrication Users Network. Five university-based research hubs are focused on electronics, biology, advance materials, optoelectronics and nano scale computer simulation.

Next Generation Internet The Next Generation Internet will eventually connect more than 100 research institutions at speeds that are 100 to 1000 times faster than today’s internet. The plan is to invest in research and development for new networking technologies and at the same time, demonstrate new applications in areas such as distance education, telemedicine, and laboratories without walls.

Center for Health Organization Transformation The Center for Health Organization Transformation is focusing on the need for multiple changes in health organizations. Funding was awarded to initiate the CHOT concept to Georgia Tech’s Milton 230 Federal Activities in Telemedicine, Telehealth, and Health Technology

Stewart School of Industrial and Systems Engineering and to Texas A&M, Health Science Center, School of Rural Public Health. The idea is for the two schools to work together and focus on the changes needed to implement IT, achieve quality and safety management, deal with chronic disease management, address clinical change initiatives, and develop other evidence-based management approaches.

Other NSF Research Activities NSF is working on novel approaches to obtain speed in the networked world, developing new middleware network service capabilities, researching satellite and other wireless technologies to help reach areas where wireline and fiber are not possible or practical, and researching new optical access technologies. Future optical backbones will use more and more optical routing so research is needed to discover how to appropriately extend the reach of these technologies.

Antarctic Program NSF manages the U.S. Antarctic Program doing research at the pole in various disciplines and is rebuilding the only scientific station located at the Pole since people spend the winter at the pole. Ray- theon Polar Services Company (RPSC) is the logistical support contractor in Antarctica. The program has used two way voice and video links between the U.S. and Antarctica to assist in medical procedures, but now they use telemedicine for surgery.

Digital Government http://www.centerdigitalgov.com The Digital Government site explains government applications created under the Digital Govern- ment program and the grants process. Grants will be awarded to academic and government collaborations to do government strategic planning for information technologies and services.

SBIR Program http://www.nsf.gov/iip/sbir The SBIR program includes Biological Informatics, Sensors, Biosensors and Diagnostics, Biochips, Genome Enabled Biotechnology, Biomedical Engineering, Research to Aid Persons with Disabilities, Biotechnology at the Nanoscale, Pharmaceutical Drug Delivery, Information Based Technologies, Infor- mation Management and Communication, Human Computer Interactions, Software Platforms, Software Engineering, Aid to the Disabled, Biotechnology, Networking and Communications, Database Creation and Management, Data storage, and Information Retrieval. SBIR topics have the potential for the healthcare field and some researchers are working on human computer interaction. Topics under biotechnology include biochips, sensors, medical informatics, biosensors, diagnostics, and instrumentation. The SBIR program is looking for biomedical engineering research that will help people with disabilities, develop biomedical devices and instrumentation, develop imaging technologies, and to help in rehabilitation

Some of Results of the NSF SBIR Program SBIR research at Nanomix Inc., in Emeryville California created a transistor that fuses carbon nano- 231 Federal Activities in Telemedicine, Telehealth, and Health Technology

tubes, polymers and silicon into a capnography sensor which is a human breathing monitor. The sensors can be used by emergency responders to verify proper breathing tube placement, monitor the patient’s respiratory patterns, and assess the effect of life support measures. Private industry developed the “Signing Avatar ™ software with grants from the SBIR Program. The software puts virtual 3-D technology widely used in video games to serve deaf students. “Andy” the avatar talks with his hands. He is a 3-D animation, displaying a distinct personality and facial expressions that help him interpret words and phrases for hearing disabled viewers on their computer screens. Andy is one of a pool of internet enabled virtual people that translates English into sign language and helps deaf and hard of hearing children develop language and reading skills. Vcom3D of Orlando Florida is marketing the assistive technology.

Partnerships for Innovation Program The Partnerships for Innovation (PFI) Program brings together colleges and universities, state and local government, private sector, and nonprofit organizations. These organizations form partnerships to support innovation in their communities by developing the tools, and infrastructure needed to connect new scientific discoveries to practical uses. PFI partnerships focus on a specific technology, industry, or geographic areas, and may request total budgets from NSF of up to $600,000 for two to three years. Proposed partnerships must include academic institutions and private sector organizations, and partnerships that include state and local governments are encouraged. 232 Federal Activities in Telemedicine, Telehealth, and Health Technology

Federal Communications Commission http://www.fcc.gov

National Broadband Plan In 2009, the FCC with the passage of the Recovery Act was charged with creating a National Broad- band plan to ensure broadband for everyone. The Commission sought input from all stakeholders

Rural Health Care Pilot Program http://www.fcc.gov/cgb/rural/rhcp.html In addition to the Recovery Act plans for broadband for the country, the FCC adopted a pilot program to help public and non-profit healthcare providers build state and region-wide broadband networks to provide healthcare services and to connect these networks to Internet2. The major goal of the pilot program is to encourage healthcare providers to join together to develop strategies for creating statewide and regional networks to connect numerous healthcare providers, including rural healthcare providers through a dedicated broadband network. The program looks at new ways that the Rural Health Care funding mechanism can help providers have access to advanced telecommunications and information services. The funding amount for the pilot program will be capped not to exceed the difference between the amount of monies committed under the existing program for the current year and $100 million. The program will fund up to 85% of the costs incurred to deploy state or regional broadband networks dedicated to healthcare, and will also fund up to 85% of the costs for connecting the regional and statewide networks to Internet2 or National Lambda- Rail. In applying for the program, applicants must identify the applicant organization and healthcare facilities to be included in the network, identify network goals and objectives, estimate network annual costs, describe how for profit participants will pay for their fair share of costs, identify funding sources for costs not covered by USF, indicate previous experience in developing and managing telemedicine programs, outline the project management plan, indicate how the telemedicine program will be coordinated throughout the state or region, and indicate the extent that the network will be self sustaining. In 2009, the FCC announced approval of funding for the program to build out five broadband telehealth networks to link hundreds of hospitals regionally in Iowa, Minnesota, Montana, Nebraska, North Dakota, South Carolina, South Dakota, Wisconsin, and Wyoming plus the FCC announced funding for a telehealth project in Alaska.

Universal Services Administration Corporation http://www.rhc.universalservice.org The Universal Services Administration Corporation administers the Rural Health Care Support Mechanism to ensure that health care providers serving rural communities pay no more than their urban counterparts for telecommunications services necessary for the provision of healthcare. The program supports monthly telecommunications charges, installation charges, and long distance internet connection charges. The FCC voted to provide rural health providers with a 25 percent discount on monthly charges for internet access. 233 Federal Activities in Telemedicine, Telehealth, and Health Technology

Some of the reforms permit for-profit rural hospitals that also operate emergency departments to receive prorated support. The Commission has decided to extend prorated discounts to non-profit entities that offer healthcare services to rural communities on a part time basis. The FCC also extended the maximum allowable distance for discountable distance-based charges from the distance from the rural location to the nearest city of 50,000 or more to the distance from the rural location to the nearest city of 50,000 or more, to the distance from the rural location to the largest city within the state. Other reforms have taken place such as:

• Telecommunications organizations providing service to rural health care providers are entitled to have the total amount of the discount applied as a credit against its universal service obligation • Eliminating the limit on the amount of funding any one telemedicine location can receive • Authorizing any commercially available telecommunications service, regardless of the bandwidth. • Allowing rural health care providers to join a consortium with other subscribers of telecommunications services and still continue to be eligible for the discounts, even if the consortium is receiving volume discounts. New members can be added to a consortium at any time • Redefining what constitutes a rural area to better target small towns and villages while still maintaining a focus on the areas with the most need • Increasing discounts available to mobile rural healthcare providers for the purchase of mobile telecommunications services • Streamlining the application process by setting an annual June 30 deadline for applications

The Rural Health Care Division enables electronic certification for two key forms in the application process. These options allow applicants to go to the USAC website and submit the forms electronically without the need to print out the form and send it. In Grant County, Washington, the program funds increased access to specialized medical resources. A telehealth network was established in the county to provide small rural hospitals with access to information and to allow them to share resources. Since there is a shortage of mental health professionals in the area, the network provides an opportunity for physicians from Spokane to consult with patients. The network provides dermatology and cardiology consultations and follow-ups from Spokane over 100 miles away. In addition to increased access to services, the network has allowed for expanded educational opportunities for medical personnel

Indian Initiatives and Services for Low Income Individuals http://www.fcc.gov/indians This site has information on FCC activities regarding Indian country rulemaking items and Native American programs at other agencies. The web site gives information on participating in the FCC rulemaking process as well as information on Tribal Land Bidding Credits available to participants in FCC spectrum auctions. The FCC also has been working very hard with the American Indian community on low-income programs that provide service to the American Indian communities. The FCC has established an outreach 234 Federal Activities in Telemedicine, Telehealth, and Health Technology

program to the Native American community and would like to extend wireline service to tribal lands. They would like to expand subsidies for all telecommunications carriers, whether they are wireline, ter- restrial wireless, or satellites that serve these areas. The FCC works to increase access to wireless telephone service on tribal lands and forming tribally-owned and operated telecommunications companies The FCC is working hard to connect the American Indians to the information age. The Indian Telecommunications Initiative (ITI) a comprehensive program to promotes understanding, cooperation and trust among American Indian tribes, Alaska Native villages, and tribal organizations, the FCC, and other governmental agencies and the telecommunications industry. The ITI program is designed to build partnerships to target specific concerns, identify potential solutions, and bring affordable quality telecommunications services to the American Indian. Specifically ITI seeks to increase the telephone penetration rate among tribal communities, facilitate the deployment of telecommunications infrastructure, provide telecommunications services, and inform tribes and tribal consumers about financial support available through federal government program including the Universal Service Fund Programs. The FCC has changed wireless auction rules to include a tribal land bidding credit to encourage the development of wireless services on tribal lands. Carriers that win licenses that overlap tribal lands can invest in serving Indian lands and deduct those costs from the auction price. In a recent PCS spectrum auction, six winning bidders have expressed an interest in using this bidding credit for service in nearly 50 markets. The FCC wants to make it possible for all low-income Americans to afford telephone service. One program, Link-up America helps qualified low-income consumers to connect or hook up to the telephone network, by offsetting $70 for initial telephone service installation costs. The other program the Lifeline Assistance Program provides qualified telephone subscribers with discounts up to $25 per month bringing basic monthly rates down to $1 per month in most cases. The Eastern Montana Telemedicine Network (EMTN) is a cooperative effort between the Deaconess Billings Clinic and five rural healthcare facilities in eastern Montana to use interactive videoconferencing to provide medical specialty and mental health services.

Federal Wireless Outreach Initiative http://wireless.fcc.gov The FCC and USDA’s Rural Utilities Service have a partnership called the Federal Rural Wire- less Outreach Initiative to help American Indians and all other individuals in rural areas. This initiative reviews respective programs and regulatory structures to provide wireless communications. The idea is to promote the exchange of information regarding rural development and telecommunications and to encourage greater deployment of wireless services. The four goals of the Initiative are to:

• Exchange information about the products and services each agency offers to expand telecommunications in rural America • Harmonize the rules, regulations, and practices whenever possible to maximize the benefits for rural America • Education partners and agencies about the FCC’s Wireless Telecommunications Bureau and USDA/RUS to provide information addressing rural needs 235 Federal Activities in Telemedicine, Telehealth, and Health Technology

• Expand the partnership so that it is beneficial to other agencies and coordinates with industry to provide information and programs

Public Safety and Homeland Security Bureau The FCC has a bureau to address public safety, homeland security, national security, emergency management and preparedness, disaster management, provide communication infrastructure protection, network reliability, plus maintain a 24/7 communications center. The Bureau plans on having a Public Communications Outreach and Operations Division to coordinate the Commission’s emergency response procedures, and coordinate related functions on a day-to-day basis during incidents or emergencies. The division will communicate with public safety organizations, state and local government agencies, and be the contact point for all inter-governmental coordination activities with other federal departments and agencies. The division will also operate the Commission’s Communications Center and High Frequency Direction Finding Capability facilities. The FCC PSHS Bureau has launched the Disaster Information Reporting System, a voluntary web- based system. Communications companies, including wireless, wireline, broadcast, and cable providers, can now report communications infrastructure status and situational awareness information during times of crisis.

Advisory Committees A Joint Advisory Committee on Communications Capabilities of Emergency Medical and Public Health Care Facilities was formed with the FCC and NTIA. The joint committee was set up to assess specific communications capabilities and to address the needs for emergency medical and public healthcare facilities. The goal is to improve basic voice, data, and broadband capabilities. The Committee is also addressing the options needed to integrate the systems with existing or future emergency communications networks and to accommodate the growth of emerging services. The FCC has an Advisory Committee on Telecommunications and Health to study many issues. This committee includes public and private sector experts and has recommended that the FCC work with other agencies to improve telecommunications to rural health care providers when the development and adoption of telehealth equipment standards and interoperability does not fall exclusively within any specific Federal agency responsibilities. The FCC has formed a Technology Advisory Council (http://www.fcc.gov/oet/tac) to make recommendations on the issues that are important to engineering and technology. This council with experts in the communications field helps provide technical expertise to the FCC on innovations and new developments. The FCC established the Network Reliability and Interoperability Council (http://www.fcc.gov/oet/ network ) to bring together leaders of the telecommunications industry and telecommunications experts from academia, consumer and other organizations, to identify and recommend measures that would enhance network reliability. The FCC established a Spectrum Policy Task Force to examine possible changes to spectrum policies, and the task force urged the FCC to promote spectrum access and flexibility to include promoting the leasing of spectrum usage rights in rural areas. This approach could open the door for greater availability of spectrum in rural areas for telemedicine applications. The FCC is examining current regulatory 236 Federal Activities in Telemedicine, Telehealth, and Health Technology

tools in delivering spectrum based services to areas that traditionally may have been underserved by telecommunications providers.

Office of Engineering and Technology http://www.fcc.gov/oet The Office of Science and Technology (OET) advises the Commission on engineering matters and how to manage the spectrum, how to create new opportunities for competitive technology, and how to provide services for people. OET plans to develop broadband services and technology. The goals are to:

• Provide the third broadband pipe into the home • 5 GHz to provide additional spectrum in both rural and urban areas for unlicensed broadband services like WiFi • Provide AWS (3G) to provide competitive mobile broadband services • Work on emerging technologies • Reduce technical regulatory barriers

The Office works on medical telemetry devices with hospitals and other healthcare facilities that use medical telemetry devices to monitor patient’s vital signs and uses wireless cardiac monitors to monitor patients following surgery. Certain medical telemetry devices use TV channels that are vacant in their area, but some of these channels may be transitioned to digital TV and no longer be available for the use of medical telemetry devices. Also, digital television services can produce interference when medical telemetry devices are in use. The FCC is studying all of the issues and working with the manufacturers of the devices and with the TV stations.

International Activities The FCC has an international initiative to provide telecom policy and regulatory assistance to developing countries to help build independent regulatory agencies equipped to facilitate universal service through competition, liberalization, and privatization. The FCC is focusing on a few key countries in Africa, Asia, Latin America, Caribbean, and Central Europe. The FCC shares experiences in regulation, open markets, competition, spectrum management, licensing, and cost-based interconnection rates. 237 Federal Activities in Telemedicine, Telehealth, and Health Technology

Social Security Administration http://www.ssa.gov The stimulus package passed in 2009 provides $500 million for SSA. Each year the Social Security and the Disability Determination Services in each state have to work with millions of Americans that file disability benefits. SSA wants to be able to handle disability claims electronically. The agency believes that this will improve the accuracy, consistency and timeliness of decision making throughout the process. The agency is asking medical providers to use electronic processes when the agency requests medical records on patients. Electronic processing is very important for SSA to be able to handle the more than 2.5 million disability benefits that Americans file for each year. As a result, SSA and the Disability Determination Services in each state are going to be able to handle disability claims electronically. The agency plans to build a $750 million mega-data center and develop new software to reduce a massive backlog of disability claims within the next five years. In 2009, $24 million was made available in contracts to provide SSA with electronic medical records to improve the efficiency of its disability programs. The agency released an RFP looking for healthcare provider networks, and health information exchanges to participate in its “Medical Evidence Gathering and Analysis through Health Information Technology” program. SSA is the first government agency to use the Nationwide Health Information Network (NHIN). In 2009, SSA started to receive medical records for some disability applicants electronically through the NHIN gateway. The electronic process will make it easier to transfer medical records securely, eliminates mail time, and automates handling so that disability applicants can receive a decision sooner, plus providers can save on resources. SSA now makes it possible for providers to use their internet connection to send patient records to a secure website or use a scanner and the internet to send batched patient files, or fax medical records to SSA. SSA has established the Future systems Technology Advisory Panel with the goal to provide independent advice and recommendations on the future of systems technology and electronic services at SSA five to ten years into the future. The recommendations of the Panel will provide SSA a roadmap of future systems technologies needed to carry out their mission.

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Federal Trade Commission http://www.ftc.gov FTC is addressing how medical identity theft should be handled in a health IT environment. Health- care stakeholders from the public and private sectors shared their knowledge and experience so that FTC would have insight into understanding of the medical identity theft landscape and how to handle future developments. The Red Flag Rule was established to deal with fraud, identity theft, and to be able to respond to the warning signs or “red flags” with the rule to be put into effect in 2009. In the past, FTC has held public workshops to examine recent trends in healthcare delivery. Topics discussed include competition and consumer protection issues regarding particular healthcare delivery innovations. The focus was on limited service clinics, price and quality transparency, and HIT. Also, a two day public workshop on “Broadband Connectivity Competition Policy” was held. Experts from business, government, the technology sector, academics, and consumers discussed competition and consumer protection issues relating to broadband internet access included the topic “network neutrality”. The FTC has held workshops on Health Care and Competition Law and Policy, studied how competition law and policy affects healthcare markets and consumer patient welfare. A range of topics discussed at the hearings and included:

• Hospital mergers • Geographic and product markets including issues unique to rural health care markets • The competitive effects of explicit and implicit contracts for quality • Institutional arrangements for the purchase, financing, and delivery of health care services • Incentives for innovations in the health care markets • Disclosure of costs, risks, and benefits by manufacturers of medical devices and pharmaceuticals both prescription and over the counter

The hearings were administered by the FTC and co-hosted with the Antitrust Division of the Depart- ment of Justice. Other agencies took part such as HHS, state attorneys generals, providers, academics, consumer representatives, employers, insurers, and managed care organizations. As a result of these hearings, the FTC and the DOJ jointly issued a report “Improving Health Care: A Dose of Competition”. The report addressed healthcare issues that affect cost, quality, and access and reviews the role of competition. 239 Federal Activities in Telemedicine, Telehealth, and Health Technology

Office of Personnel Management http://www.opm.gov The Office of Personnel Management’s Federal Employees Health Benefits (FEHB) program’s role is to ensure that records are securely transferred between medical providers. FEHB purchases health benefits coverage for more than eight million people and works closely with other purchasers and with health plans that participate in the program. Today, OPM has asked more than 250 health insurers of federal employees to maintain their health records electronically and submit plans for the information technology that they will use for electronic medical records that need to go to health plans, pharmacies, and the healthcare system in general. OPM expects the health plans to create incentives and rewards for physicians that deliver high quality care. IOM released a report that analyzed performance measures, catalogued, and evaluated “Pay for Performance” in public and private sector settings, and identified policies to align performance with payment under Medicare. OPM employees are on the HHS American Health Information Community Consumer Empower- ment Workgroup, the Quality Workgroup, and work closely with the Confidentiality, Privacy and Secu- rity Workgroup. OPM is also a member of the Interagency Health IT Policy Council. OPM will also continue to expand the FEHB web site to provide information on costs and quality initiatives as well as health IT capabilities. 240 Federal Activities in Telemedicine, Telehealth, and Health Technology

Consumer Product Safety Commission http://www.cpsc.gov The Consumer Product Safety Commission protects the public from unreasonable risks of serious injuries or death from more than 15,000 types of consumer products. Deaths, injuries and property damage from consumer product incidents cost the nation more than $700 billion annually. On a daily basis information is sent to CPSC to analyze whether individual’s injuries are a result of using consumer products. For example, all emergency department and urgent care patient records at the University of Arizona Tucson, Medical Center is reviewed, collected, entered into a standardized database, and delivered to CPSC. The University of Arizona by participating through the NEISS system is also involved in special studies. Currently, data is being collected for special studies on adverse drug events, assaults, work-related injuries, self-inflicted injuries, and firearms. 241 Federal Activities in Telemedicine, Telehealth, and Health Technology

Appalachian Regional Commission http://www.arc.gov The Appalachian Regional Commission (ARC) supports economic development in the rural areas in13 states and funds programs planning and feasibility studies, demonstration programs, and multi-sector telecommunications networks. ARC develops partnerships with other Federal agencies such as the Economic Development Administration, (EDA) Rural Utilities Services (RUS), NTIA, and TVA. The ARC matches grants from other Federal agencies including EDA, RUS, NTIA, HHS, and HUD in funding telemedicine and telehealth projects. Annually, the ARC approves funding each year for telemedicine related projects and funds new projects region-wide that have some telemedicine and telehealth components. The Governors of each state are directly involved in the selection process of all projects submitted to the ARC. The Commission’s area development program directs the Commission to work with existing federal and state agencies to help correct the region’s shortfalls in healthcare and other services. Primary care clinics built by ARC have put modern healthcare within a thirty-minute drive of most adults and children in the region.

Microsoft Unlimited Potential Software Grants Program ARC and the Microsoft Corporation have donated $1 million as part of the Microsoft “Unlimited Potential” software grants. The grants are used to support ARC’s plan for broadband deployment in rural communities in the thirteen states that comprise the Appalachian Region. The grants go to local governments, community-based groups, and educational institutions with priority given to recipients in economically distressed. Grant recipients receive training to enable individuals to acquire technology skills to help themselves and their communities.

ARC Goals The ARC wants all Appalachian residents to have affordable and quality healthcare. The objectives are to: • Increase job opportunities and income to reach parity with the rest of the country • Strengthen the capacity to compete globally • Develop and improve the infrastructure to make the region economically competitive • Build the Appalachia Development Highway System to reduce the isolation of the residents in the region

The ARC wants to bridge the digital divide by opening up Appalachia to new information services and technologies, and focus on key areas. These key areas include educating and training in new technologies, creating more job and business opportunities in emerging technologies, and assisting local governments, businesses, schools, and hospitals in developing and benefiting from e-commerce networks. ARC’s key roll is to help local communities make private sector investments feasible, build public and private partnerships to encourage these investments, and facilitate last mile connections. 242 Federal Activities in Telemedicine, Telehealth, and Health Technology

Projects Funded ARC funds many projects such as EMA and E-9-11 projects in North Carolina, Ohio, and Alabama. Projects are funded to work with the criminal justice system to use telehealth, telepsychiatry, teleradiology. The projects fund telehome and visiting nurses projects, virtual pediatrics projects, traditional consultations, informatics, and continuing education for healthcare professionals using video conferencing, and on-line internet based education programs.

ARC Online Resource Center http://www.arc.gov/index.do?nodeId=5 The resource center helps Appalachian communities with planning and working on economic and human development programs. Information is provided on:

• Resources for Community Planning with ideas for development • Regional Data & Research has statistics on the region • On information for applying for public and private grants • Information on topics in education, health, telecommunications, transportation, community infrastructure, and business development

ARC has published “Telecommunications and Technology in Appalachia Program and Impact Summary”. According to the report, ARC has invested $32.2 million in more than 250 telecom and technology projects over the past four years to make a significant impact in strengthening and diversifying the region’s economic base.

Collaborative Activities A partnership formed by ARC and the Claude Worthington Benedum Foundation along with Carn- egie Mellon University is bringing wireless broadband applications to rural Appalachia. Glenville West Virginia was the first site to receive broadband service through this program and a site in Southwest Pennsylvania will follow. The ARC has partnered with the FCC in expanding telecommunications and high-speed internet availability in the Appalachian Region. The two agencies work together to identify low-income house- holds qualifying for the FCC’s Lifeline Assistance and Link-Up America outreach programs. Digital Appalachia is a federal program to encourage private investment in new infrastructure and this initiative will also supplement the work of other federal programs such as NTIS, RUS and others. 243 Federal Activities in Telemedicine, Telehealth, and Health Technology

General Services Administration http://www.gsa.gov The report “Health IT in Government-Transforming Health Care and Empowering Citizens” was published by GSA’s Office of Intergovernmental Solutions for the Intergovernmental Advisory Board. A selection of leading edge cases describing health IT applications in the report point out the collaborative and innovative efforts taking place in partnerships within the government and private organizations.

Disabilities in the Workplace The Rehabilitation Act was amended in 1998 to require Federal agencies to make their electronic and information technology accessible to people with disabilities. Agencies must give disabled employees and members of the public access to technology that is available to others. The law applies to all Federal agencies when they develop, procure, maintain or use electronic and information technology.

Section 508 Requirements http://www.section508.gov Section 508 was enacted to eliminate barriers in information technology so that people with disabilities and are able to use f new technologies. The General Services Administration and the Access Board are directed to provide technical assistance to individuals and Federal agencies concerning the requirements of Section 508. The Federal Information Technology Accessibility Initiative is an interagency effort, coordinated by GSA to offer assistance. Contractors providing services and electronic and information technology products to Federal agencies must provide Section 508 compliant deliverables. This includes electronic and information technology that stores, processes, transmits, converts, duplicates, or receives electronic information. Specifi- cally, copiers, computers, fax machines, software, hardware, information kiosks, web sites and telecommunications products are included. Federal agencies are not required to retrofit existing technologies. Section 508 standards are organized into six sections and include software applications and operating systems, web-based intranet and internet information, telecommunications products, video and multimedia products, self contained closed products, and desktop and portable computers. The Section 508 web site offers information on the requirement of Section 508. The web site is an interagency effort coordinated by GSA, Department of Education, Department of Justice, Social Security Administration, and the Office of Management and Budget.

Office of Citizen Services and Communications Intergovernmental Solutions Division http://www.gsa.gov/intergov The Division maximizes information sharing in order to raise the awareness of the challenges facing large healthcare systems when implementing IT. The Division also identifies specific projects and the lessons learned. Projects include the North Carolina Healthcare Information and Communications Alliance (NCHIA) Provider Access to Immunization Registry Securely Project (PAIRS) Collaboration, and the Los Angeles County Public Health Information Network

244 Federal Activities in Telemedicine, Telehealth, and Health Technology

Buying Technology GSA awarded a key contract to provide federal agencies with access to a broad range of contact center services. The USA Contact contract is worth an estimated $2.5 billion over the next decade. This approach provides federal agencies with a choice of pre-approved contact center service vendors. GSA is working on the Alliant government IT services vehicle to do business. The government has issued government-wide acquisition contracts to provide a wide range of information technology services. The Alliant IT program has the potential to be a $50 billion, 10 year information technology contract. A program called Alliant Small Businesses awarded contracts to small businesses. These programs will award multiple award contracts to a number of vendors and then the winning vendors will compete among themselves for government business. GSA is reorganizing to create the Federal Acquisition Service to buy technology and other products and services on behalf of the government. In 2009, GSA selected Maryland-based Smartronix Inc., to redesign the Recovery.gov website. The Alliant contract is a multiple award, indefinite delivery, indefinite quantity Government-wide Acquisition Contract. This was the first award made under GSA’s Alliant contract and is initially valued at $9,516,324 through January 2010. If all options are exercised through January 2014, the total task order will be valued at $17,948,518. GSA awards the Veterans Technology for Services Government-wide Acquisition Contract to ser- viced-disabled veteran owned contractors. Eligible contractors are now able to compete for federal government procurements under this contract se-aside that has a five year option period and potential overall value of $5 billion. 245 Federal Activities in Telemedicine, Telehealth, and Health Technology

Small Business Administration http://www.sba.gov Business Matchmaking is a public private initiative presented by SBA, SCORE, HP and other private sector companies to match small businesses with government agencies, large businesses, prime contractors, and other major corporations. The idea is to help small growing companies find contract opportunities for products and services. The program combines education and counseling, and experts to do networking and conduct face to face appointments during regional events.

Business Matchmaking Online Network http://www.BusinessMatchmaking.com The Business Online Network has articles, educational tools, monthly webinars, interviews, a directory for buyers to use to search for companies that match their procurement needs, plus a newsletter is available with contracting updates. 246 Federal Activities in Telemedicine, Telehealth, and Health Technology

U.S Agency for International Development http://www.usaid.gov The U.S. Agency for International Development (USAID) administers economic and humanitarian assistance programs worldwide in developing countries. The agency is an independent federal government agency that receives overall foreign policy guidance from the Secretary of State and supports global health in four regions of the world: Sub-Saharan Africa, Asia and the Near East, Latin America and the Caribbean, and Europe. USAID is working in health information to improve performance monitoring systems, develop methods for evaluating cost effectiveness, to assess information needs for policy and programs, produce global and country-specific materials, expand the use of new methods, technologies and formats for effective communication, and provide a range of data collection options.

Bureau for Global Health http://www.usaid.gov/our_work/global_health/index.html

Office of Health, Infectious Diseases and Nutrition The Office is strengthening global health systems and Health Systems 20/20 is working with funding from USAID on a five year (2006-2011) cooperative agreement to help countries solve problems. A manual has been developed to provide information on doing a comprehensive assessment of a country’s health system. The manual includes technical modules which guide data collection and assessment. These include information on core modules, governance, financing, healthcare delivery, human resources, pharmaceutical management, and health information systems. Health Systems 20/20 has also held several one day workshops in various countries and in the past a workshop held in Washington D.C., helped participants share experiences on health governance challenges, issues, and practices, and to make recommendations for health systems programming. The Child Survival and Health Grants Program support health programs to advance research and transfer the technology to the field. The focus is on innovations needed to deliver underused and needed high impact intervention to help children.

Health Channel USAID takes part in the federal government’s Emergency Plan for AIDS Relief, and provides millions in funds to expand South Africa’s public health education channel. The HIV/AIDS pandemic is putting the South African public healthcare system under a huge strain. The health channel operating as a satellite broadcast channel delivers free education to patients and healthcare workers in clinics and hospitals in South Africa. The channel was created through a public private partnership between the Department of Health, Sentech, and Mindset Network. After a successful piloting of the Health Channel on the Sentech infrastructure into 56 healthcare clinics and hospitals, the Department of Health with Sentech established a strategic alliance with Mindset Network, a partnership led by Liberty and Standard Bank Foundations. The Mindset Health Channel aims to be in all 4,000 public healthcare sites in South Africa within five years, serving 97,000 nurses and 36 million South Africans dependent on the public sector. The chan- 247 Federal Activities in Telemedicine, Telehealth, and Health Technology

nel will be extended across all of Africa, and eventually, the funding will create a sustainable, mass-scale public health intervention tackling all major health problems.

Other Projects • Intel Corporation and USAID have signed a memorandum of understanding to increase the use of ICT in education, enable last mile internet connectivity, and provide support for small and medium sized businesses to improve economic development opportunities. • The Medical Missions for Children has established a system of internet video conferencing that lets volunteer doctors from 30 mentoring hospitals in the U.S. examine, diagnose and treat sick children abroad • The USAID’s Global Development Alliance invested $1 million to expand a telemedicine network throughout Latin America and the Caribbean. Satellite ground stations were built in Bolibia, Brazil, Guatemala, Mexico, and Panama to allow remote communities receive medical education programming. The ground stations can store and forward up to 120 hours or medical content for on-demand access at each of the five USAID hospital sites

Digital Opportunities Under a DOT-COM, the U.S. Agency for International Development entered into cooperative agreements with various grantees and sub-grantees to take a leadership role in bridging the digital divide in USAID assisted countries. DOT-COM is a global alliance of partners with activities crossing all sectors, including education, trade, health, telemedicine, and other areas. The Internet for Economic Development Initiative expands internet access in developing countries to build and improve e-commerce, distance education, telemedicine, and environmental surveillance. Activities are now underway in 21 countries. The program builds on the principals of USAID’s Leland Initiative in Africa. The Leland Initia- tive is a U.S. government effort to extend full internet connectivity to 20 or more African countries. The Initiative plans to improve connectivity within Africa, increase access by people living in Africa, enhance Africa’s ability to find solutions to African problems, and make information produced in Africa available to the world. The dot-ORG program extends information and communication technology access to the underserved. The grantee for dot-ORG is the Academy for Educational Development (AED) plus partners provides assistance by incorporating Information and Communication Technologies in the areas of environment, health, education. The idea is to use IT systems for crisis intervention, distance training, environmental surveillance, and telemedicine. A public/private sector roundtable was held to discuss the President’s Digital Freedom Initiative (DFI) to help developing countries use information and communication technologies to help meet challenges. USAID efforts have focused on policy and regulatory reforms as well as technology and connectivity deployments. The Last Mile Initiative (LMI) now has projects in more than 25 countries including the Macedonia Connects project. All LMIs have strong partnerships with private U.S. firms and new partnerships will be welcome under DFI.

Global Technology Program The Global Technology Network a trade and business matching program provides for the transfer of 248 Federal Activities in Telemedicine, Telehealth, and Health Technology

U.S. technology and services to address global development problems. U.S. firms are matched to country development needs to provide the appropriate technological solutions. GTN focuses on communications and information technology and health technology.

Enhanced Disease Surveillance USAID’s “Emerging Pandemic Threats Program” is building disease surveillance and training programs that include PREVENT, PREDICT, IDENTIFY, RESPOND, and PREPARE. 249 Federal Activities in Telemedicine, Telehealth, and Health Technology

APPENDIX A: LEGISLATIVE BRANCH

Library of Congress http://thomas.loc.gov The Library of Congress web site lists House and Senate members, gives information on bills and major legislation, gives bill summaries and status, gives full text of current legislation, and has information on committee reports and committee schedules. Links go to committee homepages, and to the Sen- ate, the House and Congressional Commissions.

General Accountability Office http://www.gao.gov GAO performs a variety of services such as audits and evaluations of government programs and activities. The majority of these reviews are made in response to specific congressional requests. There are a number of reports available in the areas of telemedicine, telehealth, informatics and other related areas.

Congressional Budget Office http://www.cbo.gov The Congressional Office is the watchdog on spending for programs discussed in pieces of forth- coming legislation. Recently, CBO produced an interim report on the Veterans Health Administration which credits organizational restructuring and management systems, performance measurement and information technology as contributors to the VA’s success CBO published a study “Quality Initiatives Undertaken by the VHA” in 2009 to discuss VHA’s experience with quality improvements and health IT.

Senate committees with interests in telemedicine and health IT Homeland Security and Governmental Affairs http://hsgac.senate.gov Programs are reviewed concerning bioterrorism preparedness and response, natural disaster preparedness and response, and biomedical research.

Finance http://finance.senate.gov Jurisdiction over programs authorized under the Social Security Act that are financed by a tax or trust fund Subcommittee Health Care 250 Federal Activities in Telemedicine, Telehealth, and Health Technology

Health Education, Labor, and Pensions http://help.senate.gov Jurisdiction over programs focusing on disabilities, public health, aging, biomedical research and development, and occupational safety and health Subcommittees Aging Public Health Armed Services http://armed-services.senate.gov Jurisdiction over health benefits and programs for TRICARE Subcommittee Personnel Veterans Affairs http://veterans.senate.gov Considers legislation on veterans hospitals, medical care, and treatment Agriculture, Nutrition, and Forestry http://agriculture.senate.gov Subcommittee Forestry, Conservation and Rural Revitalization

Appropriations http://appropriations.senate.gov Subcommittees Agriculture, Rural Development and Related Agencies Labor, HHS, Education and Related Agencies VA, HUD and Independent Agencies

Budget http://budget.senate.gov

Commerce, Science and Transportation http://commerce.senate.gov Subcommittees Communications Science Technology and Space

Indian Affairs http://indian.senate.gov 251 Federal Activities in Telemedicine, Telehealth, and Health Technology

House committees with interests in telemedicine and health IT

Armed Services http://www.house.gov/hasc Jurisdiction over health benefits and programs for the TRICARE system Subcommittees Military Personnel Military Procurement Military Research & Development

Committee on Homeland Security http://homeland.house.gov Reviews programs on bioterrorism preparedness and response, natural disaster preparedness and response, and biomedical research

Energy and Commerce Committee http://energycommerce.house.gov Oversight for consumer protection, public health, environmental health and also considers legislation on Medicare, Medicaid, and FDA Subcommittees Health and Environment Telecommunications, Trade and Consumer Protection

Ways and Means http://waysandmeans.house.gov Considers legislation for programs that provide payments for healthcare, Medicare, as well as health delivery systems Subcommittee Health

Agriculture http://agriculture.house.gov 252 Federal Activities in Telemedicine, Telehealth, and Health Technology

Appropriations http://www.appropriations.house.gov Subcommittees Agriculture, Rural Development, FDA and Related Agencies Defense Labor Health Human Services and Education VA, HUD and Independent Agencies

Budget http://www.budget.house.gov

Government Reform and Oversight http://oversight.house.gov Subcommittee Technology and Procurement Policy

Science http://www.science.house.gov Subcommittees Space & Aeronautics Environment, Technology and Standards

Veterans Affairs http://veterans.house.gov Subcommittee Health 253 Federal Activities in Telemedicine, Telehealth, and Health Technology

APPENDIX B Telemedicine, TeleHealth, and Health Technology Web Sites Telemedicine Information Exchange http://tie.telemed.org The Telemedicine Information Exchange is now housed within the Association for Telehealth Service Providers based in Portland Oregon. TIE has information on telemedicine research, education, management and dissemination of information about telemedicine and related activities. TIE is a comprehensive on line source of telemedicine information updated every two weeks. The site provides searchable databases with information on business news, funding, products and services, legal and ethical issues. The site provides information on home healthcare, and the history of telemedicine. TIE links to other telemedicine resources with information on consultants, distance learning, government, international activities, military, organizations, periodicals, telecommunications, teleradiology, video conferencing, and virtual reality.

Healthfinder http://www.healthfinder.gov Healthfinder is a gateway consumer health information web site for up-to-date information sponsored by the U.S. government. Healthfinder was developed in collaboration with other Federal agencies that have health communication responsibilities. Healthfinder has selected online publications, news and press releases, databases, web sites, support, and self-help groups, online medical journals, as well as government agencies and non profit organizations that produce reliable health information for the public. Healthfinder now has easy to use consumer resources with up-to-date health information that is of special interest to American Indians, Alaska Natives, Native Hawaiians and Pacific Islanders. 254 Federal Activities in Telemedicine, Telehealth, and Health Technology

ABOUT THE AUTHOR

Carolyn Bloch of Bloch Consulting Group has researched and reported on Federal government and legislative activities in the areas of science, health and technology – and has worked with many scientific and technical newsletters, publishing firms, and other companies. The author of 5 books and many articles based on Federal government activities, federal funding programs, and university research grant opportunities. Carolyn Bloch has also taught courses in proposal writing for government contracts at a number of colleges and universities. She is a member of the National Press Club, American Telemedicine Association, Healthcare Infor- mation and Management Systems Society, and the Association of Telehealth Service Providers.