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Telemedicine/Teleradiology

Contact Person: Kevin M. McNeill, Ph.D. (kevin@radiology.arizona.edu)


Introduction

In the mid-1990's the Arizona state legislature recognized the growing needs of medically underserved populations in the state. In response, the legislature provided funding in July 1996 to initiate a program to establish integrated telemedicine services for the state. Located in the Southwest of the United States, Arizona has an area of 113,909 sq. miles (295,007 sq. km) and is the sixth largest state. Slightly over one quarter (26.7%) of the state is set aside for Native American lands. Large areas of the state are other federal lands and only 17.6% of the land is privately owned. The population growth rate over the last several has been among the highest in the nation. According to the 1990 census, 18.8% of the state's population is of Hispanic origin while 5.5% is Native American. Although it has a large area, the state is divided into only fifteen counties, thirteen of which are designated as rural. Only Maricopa and Pima counties, in which Phoenix and Tucson are respectively situated, may be considered to be high-density, metropolitan areas. About one quarter of the state's population lives in rural areas covering approximately 95,000 sq. miles (246,035 sq. km). The University of Arizona Rural Health Office has identified a significantly uneven distribution of health care resources in which most rural areas are severely underserved. The geographical size and characteristics of the state impose difficult constraints which can be best met through the use of information technologies to support health care delivery, education and research.

The original legislations passed in 1996 specified an eight-site telemedicine network in which specific communities were targeted for service. Communities were specified which were under 50,000 and underserved, but over 20,000 to ensure adequate cases. The Arizona legislature defines telemedicine as "the use of computers, video imaging, fiber optics and telecommunications for the diagnosis and treatment of persons in rural, geographically isolated communities and state institutions." The program has many goals, however two key goals are the following: 1) Demonstrate how telemedicine can improve rural health care in Arizona; 2) and offer a cost-effective alternative to expensive transportation and time delays for outside referrals from the Arizona Department of Corrections institutions. [1]

In order to attain these goals the Director of the ATP organized a multi-disciplinary team capable of implementing a comprehensive program. The Director is head of Pathology and a pioneer in the application of telepathology, as well as a visionary in understanding the potential application of telemedicine to medical practice. By appointing a medical director for the program he established a firm laison with the medical providers, establishing the Telemedicine Services Component of the program. The co-director of the program also heads the Biomedical Communications division and already provides distance education for the College of Medicine. His involvement in the program, along with participation by Rural Health Office personnel, establishes the Professional Education component. In addition, his video personnel brought experise for both the technology and the training necessary for the successful use of video techniques. At the Arizona Health Sciences Center the Radiology Research Laboratory has an extensive history of work in the area of technology evaluation and assesment, as well as networking and computer engineering related to PACS development and the application of technology in radiologic imaging. Radiology Research faculty and staff were brought into the program to provide the Telemedicine Technology Assesment component, and to establish the infrastructure of the Arizona Rural Telemedicine Network. Finally, the Director of the Arizona Health Sciences Library contributes to the Telemedicine Training component by providing training to the rural client site personnel in the use of Internet resources.

As with any telemedicine effort it is critical to determine what types of technologies are needed to meet the requirements of the end users [2]. One important important technology is real-time video conferencing to support several types of interaction between the Arizona Health Sciences Center and remote client sites. Interactions include point to point conferences in which a specialist at the AHSC can interact with a physician and patient at the remote client site. They also include interactive multi-point conferences for "Grand Rounds" continuing medical education. Another key technology is asynchronous, "Store and Forward" applications in which a patient encouter is documented with images, video clips, digitized voice and scanned documents. For these applications the information is sent to the specialist and the resulting consultation report returned at a later time. These interactions are asynchronous in the sense that the local and remote physicians do not have be available at the same time. This includes teleradiology and similar applications use non-radiologic images to support diagnostic consultation for dermatology, telepathology, and other clinical interactions which can be accomplished asynchronously.

Since the Arizona Telemedicine Program is broadly based, it also includes the assesment of telemedicine technology and professional training. To support the training aspects of the program a training center has been established which provides the same equipment as that deployed at the remote client sites. Healthcare professionals from the client sites generally come to the training center for a two day intensive course in telemedicine which includes hands on training with the equipment. This training center also houses the consulting site for video interactions so course attendees can understand telemedicine from the perspective of both the client and service sides. This room is also used to introduce medical students to the techniques of telemedicine.

The assesment of technology takes place at the Radiology Research Laboratory. The laboratory is a 14,000 sq. ft. facility for basic research in Radiology and also home to the technology assesment function of the telemedicine program. In addition, the network management personnel and teleradiology servers reside in the laboratory as well. In addition to the evaluation of technical aspects of telemedicine equipment, the role of the assesment function is also to support the scientific evaluation of clinical results and outcomes of the application of telemedicine techniques. This area of research is critical for telemedicine to move from the initial technology driven deployment phase, to a period of routine clinical use. While there is growing evidence of the efficacy of telemedicine there are many issues which remain unclear. These issues include not only technical and clinical issues, but social and business issues as well. [3]

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Presentation Number SAmcneill0213
Keywords: Telemedicine, Teleradiology, Real-time, Store-and-forward, Interactive, Network


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