19.2 bit/sData

CAD/128 kbit/s ' CAM

Figure 11

ATM and SDH

The large transmission capacities of BISDN can also be achieved with the more advanced methods of Synchronous Digital Hierarchy (SDH) and Asynchronous Transfer Mode (ATM) . These methods allow the flexible allocation of a very wide range of data transmission rates .

SDH passes information in 150 Mbit/sec "envelopes ." It accommodates a wide variety of different services and data types and can multiplex/de-multiplex different parts of the envelope without having to break the whole envelope apart. It does this by using a fairly complexed pointer mechanism to identify individual communications.

Asynchronous Transfer Mode (ATM) also delivers high-capacity communications over the BISDN. It uses the concept of packet switching which divides information into small equally-sized packets called cells. Normally, packet switching cannot be used for real time communications due to delays that would destroy the conversation. ATM cells are capable of being transmitted, interpreted, and delivered fast enough to carry any kind of information in real time. ATM flexibility can handle voice, video, and data.

Radio Systems

Digital signals can also be effectively sent over radio systems such as satellites . Because radio systems do not require the installation of expensive cable, many think that satellite and other radio systems will play an expanding role in the future of communications networks .

Radio transmission of medical information can be an effective technique for "store-andforward" applications and will likely be incorporated for such uses . Error correcting devices are available that will not allow the transmission of "bad" information. Under circumstances where

a large amount of errors are associated with a particular transmission, the connection will automatically be disconnected, and the user is asked to retransmit the information .

The design of an effective communication system for telemedicine will require the optimal integration of hard-wired systems and wireless systems . Time sensitive medical information will have to be transmitted over a hard-wired network, while less time sensitive information can be sent using more cost effective wireless technology.

TELEMEDICINE APPLICATIONS

Telemedicine is currently being applied throughout the world . Many health care professionals are excited about the use of modem communications technology in providing services that otherwise would not be possible. The following examples summarize a literature review focused on the implementation of telemedicine. These examples cite three important areas where medical practitioners can benefit from telemedicine: The Computer Patient Record (CPR), Medical Imaging, and General Consultation .

Computer Based Patient Record (CPR)

The recent explosion in the use of highly technical diagnostic equipment by medical practitioners has created a mass of information stored in different forms at several different locations. The management of this information has become a major concern for administrators and practitioners alike. In response to this problem, management information systems (NIIS) were formed so that patient medical records could be stored in digital form . The MIS was the first step by the medical community to implement a computer-based patient record (CPR) .

-In 1990, a committee established by the Institute of Medicine (IOM) of the National

Academy of Sciences did an 18-month study on the implementation of a CPR system .' The main objective of the IOM study was to examine the problems with existing medical record systems and to propose actions and research for their improvement in light of new technology. The committee defined a CPR as "an electronic patient record specifically designed to support users through the availability of complete, accurate patient data, alerts, reminders, clinical decision support systems, links to medical knowledge, and other aids ." The IOM committee's main recommendation was that "health care practitioners should adopt the computer-based patient

record as the standard for medical and all other records related to patient care."

A CPR will have to be built on an ongoing basis from all the different points of patient encounters. The IOM study presents two different CPR database models ; the centralized CPR, and the distributed CPR (see Figure 12 and Figure 13) . The IOM recommends that either of

these models, or some hybrid of the two, should be used .

LAB

LAB SYSTEM

Patient Lab Date

In adepartmental (e.g.,Lab Users)

Computer-based Patient Record (CPR)

PHARMACY BILLING

Q1
:00

w

Communications
Network

Users

Figure 12

The Distributed CPR

PHARMACY
SYSTEM

Patient
Pharmacy

Date (Other Distributed Departmental Systems)

Patient
Flnaneial
Date

BILLING SYSTEM

//
Users

Healthcare Financial Management Magazine engaged several health care information systems experts in a discussion about the future of computing technology in the health care industry.' One of the questions presented to the panel was: "What impact will computer-based medical records systems have on the quality and efficiency of health care?" The responses overwhelmingly considered CPR systems to be fundamentally important for any program designed to improve the quality of health care and lower health care costs . A lack of unified medical records will have a negative effect on the quality of health care and will allow health care costs to increase in the future. The point is also made that funding the implementation of such systems may increase the cost of hospital operations for the short term. Over time, however, an investment in a CPR system will prove its worth ."

Britain's National Health Service (NHS) is made up of 22,000 hospitals, clinics, and offices. NHS has recently chosen two hospitals to begin converting medical records from paper to the computer. This initial implementation of an "electronic patient record" uses conventional telephone lines being run by Syntegra, a subsidiary of British Telecom (BT). Meanwhile, BT will bid for a bigger contract to supply an "information superhighway" to carry broadband information such as e-mail, X-rays, and video links using optical fibers. These new communications networks should connect 90% of NHS organizations by 1996 at a cost of €2 .4 million. It is expected to take almost ten years to convert patients' records from paper to digital bits.'

Medical Imaging

In today's technological environment, medical imaging products are part of a growing market. With the communications infrastructure today being vastly superior to what it was just a few years ago, medical imaging has become a preferred diagnostic tool in the medical community. Various modality machines such as CT scanners and magnetic resonance imagers contribute to the market. The application of document processing and information storage and retrieval has become an important need of the hospital, managed care, and insurance communities. Picture Archival and Communication Systems (PACS) have been developed as a way to organize modality machines with storage and retrieval systems .

PACS are also an important issue in telemedicine. A steady stream of new technology, and a changing economic and political environment have made this possible . More powerful desktop computing systems with cheaper, denser storage devices and larger, more accurate viewing screens make the idea of obtaining a primary diagnosis over the computer feasible . Faster computer networks for both local and wide area applications also contribute to the practicality of an electronic medical imaging system .

Another advantage of a PACS system is that hospitals can avoid subcontracting image reading services and contain costs within their own system. Referring physicians see PACS as advantageous because they see images faster with less inconvenience .

Image Compression

Image compression has had a lot to do with the successful development of the PACS concept. Fiberoptic digital transmission lines are widely used in the United States and in some parts of Arkansas, but normally only for a "superhighway." Most telephones are connected to this superhighway by means of a slow on-ramp called a local loop which consists of twisted-pair copper wire connecting groups of phones common to one area." The speed of data transmission is only as fast as the local loop .

Compressing the size of large image files offers a cost effective way to send them over conventional twisted pair telephone lines. Compression methods are termed either "lossless" or "lossy" depending on whether an identical copy of the file is compressed, or a slightly altered copy of the file is compressed . Lossy compression reproduces image files that are visibly indistinguishable from the original file even though the file is altered . The advantage of lossy compression is that it compresses files to one-fifth the size of a lossless compression . The most common form of lossy compression is Joint Photographic Experts Group. (JPEG). JPEG compression allows digitized images to be sent in one-tenth of the time it would take to transmit an uncompressed file.

Teleradiology

Teleradiology is a technology that digitizes radiographic images and transmits them from one computer to another." Teleradiology has the potential to help support hospitals and clinics in rural areas who do not employ a radiologist . Teleradiology is the application of telemedicine that is currently the most widely tested. In 1994, approximately 15 interfacility teleradiology programs in North America provided teleradiology services to about 90 remote sites and interpreted approximately 22,000 studies . ¹²

The amount of attention given to teleradiology is well founded. In many cases, an acceptable remote medical consultation can be conducted without the use of full-motion video . The combination of high quality medical images provided by teleradiology and an ordinary telephone is usually all that is needed." With the advancement of certain image compression techniques such as JPEG and fractal compression, teleradiology is substantially less expensive than full-motion video telemedicine. ^17,18

Other studies have been done to test the diagnostic reliability of examining digitized recreations of radiological images as opposed to conventional radiographs . A study conducted in Norway from April of 1992 to January of 1993 concluded that radiologic consultations using existing teleradiology equipment and regular telephone lines can enhance remote diagnostic services. 22 In this case a mobile MRI unit was dispatched for 118 days and was serviced by eight general hospitals. During the test period, 43 requests for diagnostic confirmations were made using the teleradiology system . In 20 of these cases, the teleconsultation resulted in a change in diagnosis .

Another study by Korsoff, Kallio, Kormano, and Heinila20 suggests that accurate

diagnosis of pulmonary disease is possible with teleradiology . This study involved the chest radiographs of43 patients sent to five radiologists using 1024x1024 pixel resolution. The radiologists were informed before the diagnosis which pulmonary diseases were suspected .

In another more stringent test done at Johns Hopkins Medical Institution ²¹ it was concluded that teleradiology was unacceptable for primary interpretation of radiographs . This study involved 16 physicians that were radiologists, resident radiologists, emergency medicine physicians, or resident emergency medicine physicians . The images were transmitted with a spatial resolution of 1200x1600 pixels . One hundred and twenty cases of various patient conditions were interpreted, and the physicians were not asked to interpret the presence or absence of any specific condition. Most of the cases were considered "diagnostically difficult", even when being interpreted using conventional radiographs .

It can be seen from the above examples that teleradiology is successful under circumstances in which confirmations of a diagnosis need to be made . However, teleradiology is not yet as accurate a diagnostic tool as conventional radiology . The Johns Hopkins study is, however, influenced by the fact that the physicians involved in the study were all trained to interpret and used to interpreting conventional radiographs. The fact that the current population of physicians are most likely trained in a similar way further validates the Johns Hopkins study.

The results of the Johns Hopkins study does not infer that the importance of teleradiology is in any way diminished . In fact, the authors of the study state that they "share the view that the goal of achieving a filmless radiology department has merit", but that they "encourage caution regarding the equivalence of radiograph and screen interpretations of emergency department radiologic cases.""

Wireless Teleradiology

The use of a wireless telephone systems to improve access to tertiary consultants needs to be examined in cases where expensive fiberoptics and digital networks are not available . Wireless systems require the use of high speed modems that are specifically designed for cellular transmissions. The performance of error detection and correction devices within the modem becomes the bottleneck in the wireless transmission process.

In a study by Yamamoto'8, several portable wireless teleradiology systems involving current technology were tested. Discussion of these systems suggest that wireless teleradiology and fax transmission using cellular telephones and pocket notebook computers is feasible . The study found that "transmission errors did not affect the quality of the image file, because these errors were detected and the data was re-transmitted to correct theerror.il" If the amount of errors being transmitted was too high, the communication system ceased to transmit and requested that the user try again.

Clinically useful radiographic images require anywhere from 40,000 bytes to 400,000 bytes of memory. Therefore a typical transmission speed of 8,000 baud (or 800 bytes per second) involves a transmission time of 1 to 10 minutes if the file is not compressed . Image compression using JPEG would allow these times to be reduced by one-tenth.

Cellular phone systems are in the process of converting to a digital format . This conversion will improve the voice and data transmissions over cellular . Cellular transmissions are currently best suited for sending documents and image files. Future cellular users may be able to access channels reserved for special applications requiring high bandwidth such as full-motion video.

Telemedicine and the Internet

The National Information infrastructure is a federal initiative envisioned as a seamless web of computers, communications networks, and databases that will make enormous amounts of information available to U.S. citizens from all professions. The National Library of Medicine (NLM) now sponsors an Internet Connections Program to provide grants to medical centers . that wish to connect to the internet .' Most health science libraries are familiar with graphical interfacing software such as Netscape or Mosaic which offers a user-friendly way to access the internet. NLM made a total of twelve contract awards in 1993 and 1994 for health care applications on the internet such as CPR's and medical imaging, rural telemedicine consultations, and medical education and training programs .'

The internet is being used by clinicians, students, and researchers to access radiological information. In New Brunswick, New Jersey, the Robert Wood Johnson Medical School's Department of Radiology has made its entire database of clinical reports and selected images available to anyone through the internet.19 The use of graphical interfacing software in a server/client atmosphere allows users to access a database by filling out a "form" on-line. The form requests information such as a physician's name and password. For non-confidential information, the user would enter any database field that they would like to search. A list is generated after a field is specified so that the user can make further selections . The system is based on the concept of hypertext, in which key words and icons in a document act to link the user to other documents and images in an interactive "point and click" environment.

In an article entitled Computers in Radiologic Education the authors point out the need

for a teaching file that can be widely accessed." Because film-based teaching files are difficult to obtain, expensive to store, and easily lost or damaged, it is becoming necessary to maintain a digital library of such files . Storing teaching files in this form allows them to become available globally through the internet. The practical aspects of storing medical files digitally is making the internet a valuable and cost effective resource for information .

General Consultation

In a recent demonstration on the use of video conferencing and medical imaging, GTE showed that a medical diagnosis using telemedicine has become a reality . The demonstration linked physicians in Canada and Venezuela to a physician and patient in the Dominican Republic. Using an ENT (ear, nose, throat) videoscope and a video dermascope (for examining layers of skin), the physicians consulted as if they were all in the same room. The physicians diagnosed the patient with a perforated eardrum and concluded that a skin lesion was not malignant. To confirm their diagnosis, the physician in the Dominican Republic called on a third physician in Honolulu to display information about perforated eardrums on the TEACH system, a telemedicine and teaching program used in Hawaii .'

Medical College of Georgia (MCG) in Augusta currently connects six rural sites with 22 more sites planned to come on line this year. MCG's system is one of the most sophisticated examples of telemedicine to date. It adapts video conferencing through a variety of special attachments. The system has been successfully used by an MCG cardiologist in Augusta to consult with a primary-care physician in Eastman, 150 miles away, to simultaneously examine the cardiogram of an Eastman woman. As a result, the woman was able to receive complete care in her local hospital near her home .'

A similar system is used in Billings, Montana where an orthopedic surgeon examines the skin graphs of a patient more than 230 miles away. Using a live video hookup, the surgeon advised a primary-care physician in rural Glendive on how to remove the staples and care for the wound.'

Telemedicine brings specialist medical knowledge to remote communities in northern Norway by connecting them to the University Hospital of Tromso . The quality of medical images is good enough to secure a diagnosis and to conduct consultations with specialists. 10

East Carolina University in North Carolina has reduced the price of a physician's consultation with prisoners from $700 to $70 with the use of telemedicine . In addition, no prisoners have escaped during a telemedicine visit. The service has been extended to rural hospitals in North Carolina. 10

WellCare has developed a 24 hour telemedicine link between hospitals in Saudi Arabia and the Massachusetts General Hospital (MGH) in Boston. MGH guarantees a diagnosis within 48 hours. Live consultations can also be arranged."

In each of these examples, the cost of transportation for receiving medical services is substantially reduced. U.S. citizens logged more than a trillion miles of travel for medical services in 1992 . Just one helicopter ride to an urban medical facility can cost as much as $3000 . A study by Arthur D. Little of Cambridge Massachusetts estimates that telemedicine could save Americans as much as $39 billion a year in medical consultation costs.' The quality of care when using telemedicine is further enhanced by the fact that patients can heal in home town hospitals near family and friends .

BARRIERS TO TELEMEDICINE

The use of any new technology creates initial barriers that must be overcome as a part of the implementation process. Telemedicine is no exception. In fact, many issues arise due to the sensitive nature inherent in the practice of medicine. People react very differently to changes in the way they see their physician as opposed to the way they see their auto mechanic or their banker. The following section will summarize some of the major barriers that are coming to light as the concept of telemedicine advances .

Adjustment to New Technology

One of the obstacles inhibiting the widespread use of telemedicine is the physicians' resistance to new technology." Mostly older rural physicians who didn't grow up around computers and who don't want to take the time. to learn have the biggest problem adjusting. . Other physicians in rural areas travel from community to community and have built personal relationships that they feel would be hurt by telemedicine.

The rural physician also might have reservations about the urban hospital being so closely connected to his or her patients . After all, rural physicians are naturally concerned about keeping their customers. With the introduction of the "urban specialist" into the rural market, the rural practitioner is exposed to more competition .

Compatibility of telemedicine equipment is also an adjustment that needs to be addressed early on. Cooperation among all health care providers and health information networks needs to be emphasized with respect to the procurement of new equipment to insure that telemedicine facilities are integrated and easy to use. Attention needs to be focused on a nationwide effort to promote seamless interconnectivity.

Cost

Cost is another potential barrier for the rural hospital. The most obvious savings associated with telemedicine are lower travel costs and less time taken away from work for the patient. ¹² But these types of savings are not currently included in the cost accounting for the health care industry. It is important that the long-term economic advantages of creating a healthier society be considered as well as the immediate benefits realized outside of the health care industry.

Telemedicine demonstration projects need to be partnered with private industry to ensure the project is adequately financed. There will be many potential players in the development of telemedicine. Public health care funding coupled with the private utility and insurance industries

will most likely take a leading role.

Transmission costs also must be lowered if telemedicine is to become economically feasible to rural hospitals. Rural residents have traditionally paid more for telephone services based on distance, and many of the current telecommunication regulations place a costly burden on rural services.' Analysts suggest that a special service rate be established for rural health and social services .' Telephone companies also need to offer "band-width on demand" instead of the current service options that force broadband users to lease dedicated lines that lay dormant most of the time.

Many issues involving the cost of telemedicine can be addressed by sharing services with other interests such as distance learning programs, electronic shopping, telecommuters, and government and social services . The more users that the system supports, the lower the cost will be to each participant. Rural communities will also benefit by accessing other services in addition to telemedicine.

Security

Privacy and security issues are also important to consider . There is an innate loss of privacy with the use of telemedicine . This tends to close out certain types of consultation where patient information is of a sensitive nature. Security is also of concern with paper-records, but what makes electronic records different is the amount of information that could potentially leak during a breach in security." The issue of ownership of information being electronically transmitted has to be dealt with in the proper way .

Coupled with the need to protect the confidentiality of patient data is the need of health care institutions to secure information for the purpose of maintaining a competitive edge . The medical industry, like any industry, is driven by market forces . Any pooling together of information might be seen along the same line as revealing "company secrets" . This issue specifically applies to the concept of sharing information in an industry wide electronic patient record.

Liability and Licensing

Licensing laws sometimes restrict physicians from practicing in more than one state without multiple medical licenses . Such restrictions need to be relaxed in cases where telemedicine is being used. State licensing officials should look at a telemedicine consultation from the viewpoint that the patient is being "electronically transported" to the physician rather than the physician being transported to the patient .' Also, the adoption of uniform licensing standards is necessary to allow medical specialists to offer their services throughout the country .

Malpractice is also a concern for physicians using telemedicine. Misconceptions about new technology (such as digital compression) could influence the outcome of malpractice cases . For this reason, policies need to be established to set the standard of care for teleconsultations, diagnosis and treatment, and for the transfer of clinical data among different medical facilities ." ^. Consulting physicians will then be able to ensure that their technical systems meet these

standards and reduce their risk of liability .

Liability is a barrier that some physicians see as inherent in the use of any new technology. As more and more successful trials are demonstrated and the standards for care using this technology become clearly defined, the medical community will no longer strongly associate liability issues with telemedicine .

All of the above barriers will be addressed and overcome in time. The medical community is aware of the overwhelming benefits that the use of telemedicine will bring, and this knowledge will motivate the appropriate actions necessary to address these and other problems. Such actions will allow the medical industry to become better equipped to provide a higher level of quality and service at lower costs .

TELEMEDICINE NETWORKSINOTHER STATES

The medical community has seen the need to explore the concept of telemedicine. Test projects have been started and are being studied and funded throughout the United States and Europe. North Carolina, Iowa, and Georgia are three states that are testing the use of telemedicine . The results of these trials will provide valuable information as to the best way to design and use telemedicine throughout the nation .

The following section will summarize the projects being tested in North Carolina and Iowa. Examples from these states will provide valuable information as to how best to construct a telemedicine system.

The North Carolina Information Highway

A model of an advanced computer communications network currently being applied to health care can be found in the November/December 1994 issue ofIEEE Network Magazine.25 The entire issue is dedicated to the North Carolina Information Highway (NC" (see Figure 14).

Winston-Salem
Greensboro

Figure 14

Details concerning the hardware and software that make up the system, as well as its financial development and its applications to education, criminal justice, state economics, government efficiency, and health care are provided. The following will summarize the NCIH as an example of how modern communications technology can be used to improve health services. The NCIH is an example of what the state of Arkansas might consider doing in terms of telemedicine.

The NCIH is a broadband telecommunications network that utilizes asynchronous transfer mode (ATM) switching and synchronous optical network (SONET) transmission equipment (see Figure 15) 29. Health care applications over the NCIH are presented in two examples. The first is a high-performance networking system called VISTAnet used for a dynamic radiation therapy planning application . The second example is called the Medical Information Communication Application (MICA) which makes it possible for many forms of medical information to be shared simultaneously by various health care providers .

r

Long-distance ATM network

Figure 15

VISTAnet offers practitioners of radiation therapy in North Carolina the ability to interconnect supercomputer elements from several locations which are essential in conducting medical imaging tasks. In radiation therapy, the goal is to maximize the radiation dose to the cancerous tumor while minimizing damage to the surrounding healthy tissue . One of the problems with radiation therapy is that it is very difficult to optimize such a treatment plan . Physicians typically use two dimensional CAT scan or MRI views of an anatomy and rely on computers to calculate radiation doses and the pattern of exposure. VISTAnet permits this process to be done interactively while viewing a three-dimensional image of the patient's anatomy. The VISTAnet process allows much safer and more accurate radiation treatment through increased computer power provided by a broadband telecommunications network .

Project MICA shows that health care applications can be greatly enhanced by the transmission and switching capability of an ATM network . The various forms of health care information such as patient records, billing and insurance documents, research databases, medical images (X-rays, CAT scan, sonograms, etc.), schedules, and teaching aids can all be shared simultaneously among health care providers . An ATM network also allows video conferencing services to promote geographically dispersed and interdisciplinary collaboration . The difference between MICA and other network consultation efforts (teleradiology, telemedicine, etc.) is that its aim is to create a comprehensive form of integrated health care

services as opposed to sub-specialty consultations . The main idea behind MICA is to encourage the broad spectrum of health care institutions such as hospitals, clinics, social services, and dentistry to re-examine their current service delivery systems .

The first phase of the MICA project also deals with radiology. The process of radiological and other specialty examinations requires numerous conferences among several health care professionals. The primary physician, the radiologist, and the technologist all need access to various forms of patient information as well as direct opinions from each other . The availability of MICA allows this process to happen faster with less inconvenience .

The use of a broadband communications network to deliver health care addresses two critical issues: cost and access. Modern communications technology can link health care professionals to rural areas at affordable rates . This connection can take the form of a second opinion from an expert radiologist examining digitized X-ray images, or a dermatologist remotely determining the severity of a skin lesion . It should be pointed out that both of these consultations can take place without a broadband network, but the result is increased inconvenience and cost due to medical professionals and patients having to wait for transmission.

Iowa's National Laboratory for the Study of Rural Telemedicine

In an effort to promote the application of emerging communications with the delivery of health services, the National Library of Medicine offered a Broad Agency Announcement and Request for Proposals entitled "Biomedical Applications of High Performance Computing and Communications" on May 20, 1993 .28 The University of Iowa was awarded a $7.25 million contract to conduct a three year study of rural telemedicine. The study involves the development of four components: a Resource Center, three test-bed hospitals, two information support projects, and three clinical support projects.

The Resource Center acts as a support mechanism for the other project components . In addition to implementing the project objectives and directing the program budget, the Resource Center coordinates activities at the test-bed sites, supervises program designs and research methodologies, implements the computer and communications mechanisms, and creates the medical database necessary to support the broad scope of telemedicine. In essence, the Resource Center is the "brain" of the network . It's director in many ways controls the development of the project.

Three hospital test-bed locations were picked to represent the Iowa project . Van Buren County Hospital in Keosauqua, Iowa is the smallest of the three and is classified as a Medicare rural hospital which serves a poor rural county ." The Ottumwa Regional Medical Center is the second test-bed location and it serves a more prosperous rural county. And thirdly, the largest test-bed location picked is the west campus of the Genesis Health System. Genesis West is classified as an urban facility.

Two information support services are incorporated into the project . The first is the Hardin Library which provides electronic health sciences library services . The Hardin Library greatly enhanced the medical information that was available to the test-bed hospitals before the project started .

The second information resource the project has made available is the Virtual Hospital (VH). The VH is a continuously updated medical multimedia database that can be accessed twenty-four hours a day. The VH provides patient-care support and distance learning through the internet using Mosaic or other interfacing software. Within the VH, the University of Iowa is creating the "Iowa Health Book" to provide citizens with instructional health information .

The clinical support projects being studied in the Iowa telemedicine program have to do with two applications of teleradiology, and a rapid computer-based information exchange for trauma patients. The first teleradiology-related projects will study the accuracy, timeliness, and cost-effectiveness of routine and subspecialty radiograph interpretations. The second teleradiology-related project will support a more advanced three-dimensional analysis of radiographs. And the rapid response computer-based information system will be designed to improve the treatment of trauma patients in rural emergency rooms .

The concept of a "laboratory" approach to the study of telemedicine will make the Iowa project an invaluable source of information as other states develop telemedicine networks . The questions that the Iowa project is designed to answer are as follows :28

1) Is the specific knowledge of the provider or patient changed or enhanced by

telemedicine?

2) Has there been a measurable change in the patient's health status, functioning, or

quality of life because of the application?

3) Is telemedicine a cost-effective alternative to current practice?

4) Is it financially feasible to implement telemedicine on a widespread basis?

5) What factors facilitate or inhibit rural practitioners' use of telemedicine?

6) Does telemedicine help recruit or retain rural health care workers?

Answering these questions are the basis of the project's work . The project is due to be complete after three years, or in May of 1996 .

TELEMEDICINE INITIATIVES INARKANSAS

Arkansas has also started to test the communications technology that is needed to support telemedicine. Three recent examples are evidence that the foundation for telemedicine in Arkansas is beginning to be built. First and foremost, Southwestern Bell Telephone company has committed $8 million toward building fiber optic hubs throughout the state by December of 1996.27 Secondly, the University of Arkansas for Medical Sciences has been working closely with Southwestern Bell on a distance learning project which utilizes this fiber network to help

train medical residents in rural areas . And thirdly, a new legislative committee has been formed to develop a statewide health information management network . These actions can be seen as the beginning of the development of telemedicine in Arkansas .

The Arkansas Telecommunications Infrastructure

Currently the telecommunications infrastructure in Arkansas is in the process of converting to T1 lines for the transmission of voice, video, and data . Southwestern Bell Telephone has also committed $8 million to developing fiber optic parks throughout the state as a part of the settlement of an over-earnings dispute ." Existing "fiber parks" (as of the date of this report) are located in Fayetteville, Jonesboro, Pine Bluff, Camden, El Dorado, and Magnolia. Southwestern Bell announced on August 11, 1995 their selection of five more Arkansas cities in which to locate fiber optic telecommunications parks . These five locations are Rogers, Fort Smith, Blytheville, West Memphis, and Arkadelphia . The new infrastructure is designed to benefit industries that are dependent on high-speed telecommunications services . The medical communities in these areas will be the most likely candidates for the development of telemedicine programs.

Southwestern Bell has structured the implementation of fiber optics in Arkansas to make sure that the facilities are spread evenly across the state . The concept of modernizing Arkansas' telecommunications infrastructure has been based on helping attract industry to the rural parts of the state. This philosophy grants rural communities the same communications capabilities found in metropolitan areas and is consistent with many of the same goals of telemedicine .

It can therefore be seen that the necessary steps are being taken today to build the infrastructure that will be needed for a modern telemedicine system . Designing and implementing telemedicine will then be dependent on medical practitioners and consumers demand for such services.

A Proposed Health Data Network for Arkansas

On August 17, 1995 a panel was created to promote the development of a statewide telecommunications infrastructure to support a health information network ." The network concept suggests a system in which medical records could be instantly retrieved from a statewide database.

The Governor's Telecommunications and Information Advisory Board will control almost $4 million to improve telecommunications in the state government . The Foundation for Arkansas Health Care is the organization behind the proposed health care network .

Representatives of the organization plan to begin a pilot project in Phillips County and also develop a network for mental health services. It is estimated that the project could save $5 .6 million from reduced Medicare and Medicaid expenses .

Distance Learning Projects in Arkansas

Many of the practical applications of telemedicine have been initiated in Arkansas through the University of Arkansas for Medical Sciences and its implementation of "distance learning" to train medical students in rural areas using compressed video . The image compression applications and networking infrastructure used for distance learning can be utilized for telemedicine and the development of high quality health services for rural Arkansas .

The Area Health Education Centers Program (AHEC) has been in existence in Arkansas since 1973 and serves six regions throughout the state (see Figure 16) . The Arkansas AHEC Program is designed to focus on the shortage of primary care physicians in non-urban areas by educating residents in a non-urban environment and then providing medical school graduates with the necessary resources to successfully practice in non-urban areas . AHEC also trains nurses, pharmacists, and other health related professionals to support the needs of rural communities.

f AHEC-Northwest

f

AHEC-Northeast

* AHEC-Fort Smith

f

AHEC-Pine Bluff

AHEC-Southwest

f

f

AHEC-South Arkansas

Figure 16

The AHEC Program has advanced the concept of using modern telecommunications and

computer networking to provide high quality health services to remote areas of the state . Other

programs have joined AHEC in utilizing the fiber optic hubs being provided by Southwestern

Bell (see Figure 17) . The new fiber optic rings that are planned for the state (see the section

entitled "The Arkansas Telecommunications Infrastructure") will allow the current networking

Figure 17: Compressed Video Network

capabilities of Arkansas to expand. This in turn will increase the demand for distance learning and telemedicine in Arkansas .

A Conceptual Telemedicine Network for Arkansas

Figure 17 provides an example of how the networking infrastructure for telemedicine in Arkansas is forming. Southwestern Bell Telephone has plans to supplement the five fiber optic hubs shown in this diagram with additional hubs in Rogers, El Dorado, Magnolia, Camden, Blytheville, and West Memphis. The information gathered from telemedicine trials being conducted through the UAMS system and the results from trials in other states will help the planners of telemedicine decide what is best for our state .

It is clear that the infrastructure being installed today will provide the needed telecommunications capacity for a broadband system . ATM trials have already started at UAMS. Powerful computing capabilities such as those being used in the North Carolina Information Highway are options that will soon be available in Arkansas .

A computer-based patient record (CPR) will also be possible and is currently being

considered by the state government . Results from trials like the Iowa study (see section entitled "Iowa's National Laboratory for the Study of Rural Telemedicine") will be instrumental in forming an Arkansas CPR. The Federal government is already taking steps to require the formation of a national CPR network consisting of the different CPR initiatives in each state.

Picture Archiving and Image storage and retrieval systems are becoming reliable and accurate. Teleradiology trials have been well documented and successful for many applications. Image compression techniques that retain the necessary information for an accurate diagnosis have allowed this to happen. The broadband capabilities of fiber optics will allow PACS to be effectively incorporated into the statewide medical information network .

Real time teleconsultations have also been tested using advanced computers and communications. Even though the need for these types of consultations will be infrequent compared to the other functions of telemedicine, the capability to conduct a "live" teleconsultation will be an available option over a broadband ATM network . The cost for such an application will be higher than for the more common "store and forward" technique, but will still be substantially less than the cost of transporting patients . The primary physician will have to decide when such a consultation is needed.

CONCLUSIONS

The concept of health care reform is one that is embracing the fast-paced changes in communication technology. It is apparent from the literature that the time is rapidly approaching when the medical community will dramatically alter the way it delivers its services. Practitioners who wish to remain competitive in the future will have to offer the market easier access to health care . Advanced telecommunications techniques will be a fundamental tool in the effort to bring health care costs down and to enhance the quality of health services being provided to the public .

The consolidation of advanced medical technology and practitioners in centrally located areas has recently presented a problem for people living in rural areas . The rural segment of the health care market has brought back the concept of home-delivered health care. Not too long ago the idea of the old fashioned "house call" was seen as impractical . Today the incorporation of digital telecommunications for public use has forced the medical community to reconsider the notion of taking their services to the public instead of requiring the public to come to them .

Examples of rural health care delivery systems are becoming common. Communications networks such as the North Carolina Information Highway are making such systems possible. Providers of telecommunications services are committed to installing the equipment necessary to support systems such as the NCIH . The infrastructure for digital communications will blanket most areas of Arkansas and will either allow mobile units to "plug in" at each community or allow an area physician to successfully live and practice in rural areas.

The concept of an information highway for the delivery of health services should

incorporate three important ideas: the development of a computer-based patient record ; second, the creation of a Picture Archiving and Communications System; and third, the promotion of one on one physician/patient consultations. To be effective, all three of these concepts will have to be supported by a broadband digital communications system. The availability of digital telecommunications is growing throughout the state, and the advanced method of asynchronous transfer mode is being supported as the next upgrade for Arkansas telecommunications.

Cooperation between the telecommunications industry and the medical community' in Arkansas has begun to bring health services to rural areas using modem networking . The different aspects described in this report concerning health care and communications are achievable and necessary to improve the delivery of health care in our state.

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