"Health Care Disparities in Rural Areas FACTSHEET Advancing Excellence in Health Care Agency for Healthcare Research and

d Quality Selected Findings From the 2004 National Healthcare Disparities Report." Agency for Healthcare Research and Quality, Advancing Excellence in Health Care www.ahrq.gov. AHRQ looked at population analysis for diseases. They found that diabetes was more likely to be uncontrolled in rural areas requiring more frequent hospitalizations. Abu-Akel, F. (2010). "How to achieve the full potential of telemedicine. Hospitals can enhance mobility to promote quality and cost-effective care by utilizing the proper telehealth solution." Health Management Technology 31(11): 16-17. From a system design approach, a mobile telehealth workstation should have the right battery chemistry, efficient teleconference equipment, wireless connectivity, proper size monitor and small form factor. Above all, the workstation should be intuitive to use and reliable. Only then will clinicians be able to devote their full attention to the most important task at hand: taking care of the patient. Through a system design approach, healthcare organizations can achieve the full potential of telemedicine by improving patient outcomes while containing costs and increasing overall clinician efficiency. Agarwal, S. and C. T. Lau (2010). "Remote health monitoring using mobile phones and Web services." Telemedicine Journal & E-Health 16(5): 603-607. Diabetes and hypertension have become very common perhaps because of increasingly busy lifestyles, unhealthy eating habits, and a highly competitive workplace. The rapid advancement of mobile communication technologies offers innumerable opportunities for the development of software and hardware applications for remote monitoring of such chronic diseases. This study describes a remote health-monitoring service that provides an end-to-end solution, that is, (1) it collects blood pressure readings from the patient through a mobile phone; (2) it provides these data to doctors through a Web interface; and (3) it enables doctors to manage the chronic condition by providing feedback to the patients remotely. This article also aims at understanding the requirements and expectations of doctors and hospitals from such a remote health-monitoring service. Albert, S. M., G. J. Shevchik, et al. (2011). "Internet-based medical visit and diagnosis for common medical problems: experience of first user cohort." Telemedicine Journal & E-Health 17(4): 304-308. OBJECTIVE: Internet-based medical visits, or "structured e-Visits," allow patients to report symptoms and seek diagnosis and treatment from their doctor over a secure Web site, without calling or visiting the physician's office. While acceptability of e-Visits has been investigated, outcomes associated with e-

Visits, that is, whether patients receiving diagnoses receive appropriate care or need to return to the doctor, remain unexplored. MATERIALS AND METHODS: The first 156 e-Visit users from a large family medicine practice were surveyed regarding their experience with the e-Visit and e-Visit outcomes. In addition, medical records for patients making e-Visits were reviewed to examine need for follow-up care within 7 days. RESULTS: Interviews were completed with 121 patients (77.6% participation). The most common type of e-Visit was for "other" symptoms or concerns (37%), followed by sinus/cold symptoms (35%). Back pain, urinary symptoms, cough, diarrhea, conjunctivitis, and vaginal irritation were each less frequent (<10%). A majority, 61% completed e-Visits with their own physician. The majority of patients (57.0%) reported receipt of a diagnosis without need for follow-up beyond a prescription; 75% of patients thought the eVisit was as good as or better than an in-person visit, and only 11.6% felt that their concerns or questions were incompletely addressed. In a review of medical records, 16.9% had a follow-up visit within 7 days, mostly for the same condition. Four of these were on the same day as the e-Visit, including one emergency department visit. CONCLUSIONS: Outcomes for the e-Visit suggest that it is an appropriate and potentially cost-saving addition to in-person delivery of primary care. Angstman, K. B., S. C. Adamson, et al. (2009). "Provider satisfaction with virtual specialist consultations in a family medicine department." Health Care Manager 28(1): 14-18. Virtual consultations (VCs) are being ordered by primary care physicians in 1 large multispecialty clinic, replacing face-to-face visits with specialists. Virtual consultations involve electronic communication between physicians, including exchanging medical information. The purpose of this study was to assess provider satisfaction with VCs via e-mail survey. Although approximately 30% of the 56 family medicine providers had not tried the VC system after it had been in place for over a year or said that they often forgot that VCs were an option, most of the providers surveyed (73%) felt that VCs provided good medical care. A majority felt that VCs are a cost-effective and efficient tool for our department (65%). Most specialists (81%) reported that VCs were an efficient use of their time, and 67% said that VCs were less disruptive than contacts by telephone or pager. Only 5% felt that VCs do not provide good medical care. Although several of our primary care providers have been enthusiastic about VCs, others have been reluctant to adopt this innovation. Specialists providing VCs tended to be supportive. This illustrates both the difficulty of incorporating e-health innovations in primary care practice and the potential for increased efficiency. Angstman, K. B., J. E. Rohrer, et al. (2009). "Impact of e-consults on return visits of primary care patients." Health Care Manager 28(3): 253-257. Virtual medicine is growing in importance as the cost of medical care rises and the potential for Internet applications expands. The purpose of this study was to evaluate the impact of e-consults (ECs) (also known as virtual specialty consultations) on the frequency of return visits for family medicine patients. Two

groups of patients were compared: those for whom an EC was requested (n = 228) and a comparison group for whom face-to-face referrals occurred (n = 500). Two types of early return office visits were used as dependent variables: those within 2 weeks for any reason and those for the same reason. No significant difference was found in rates of early return visits for the same reason. The percent of return visits for any reason within 2 weeks was 38.2% for EC patients and 27.6% for patients receiving face-to-face specialist visits (p < .01). After adjusting for comorbidity, age, sex, and marital status, the odds of an early return visit for any reason after an EC were elevated (odds ratio, 1.88; confidence interval, 1.33-2.66; P < .01). E-consults by referral specialists were associated with increased odds of early return visits for primary care patients with a primary care provider. Armstrong, A. W., C. Sanders, et al. (2010). "Evaluation and comparison of store-andforward teledermatology applications." Telemedicine Journal & E-Health 16(4): 424-438. OBJECTIVE: Store-and-forward (S&F) teledermatology has been used to increase patient access to dermatologic care. A major challenge to implementing S&F teledermatology is selecting secure and cost-saving applications for data capture and transmission. Detailed analyses and comparison of the major S&F teledermatology applications do not exist in the current peer-reviewed literature. The objectives of this study were to identify, evaluate, and compare the major S&F teledermatology applications in the United States to help referral and consultant sites select applications responsive to their needs. MATERIALS AND METHODS: We identified four major, commercially available S&F teledermatology applications after surveying the members of the American Telemedicine Association Teledermatology Special Interest Group and the Telemedicine Task Force of the American Academy of Dermatology. A multidisciplinary team of dermatologists, primary care physicians, and information technologists established a set of criteria used to evaluate the applications. We performed a comparative analysis of the four major S&F teledermatology applications based on the predetermined evaluation criteria. RESULTS: The four major, commercially available S&F teledermatology applications evaluated in this study were Alaska Federal Health Care Access Network, Medweb, TeleDerm Solutions, and Second Opinion. All four teledermatology applications were mature and capable of addressing the basic needs of S&F teledermatology referrals and consultations. Each application adopts different approaches to organize medical information and facilitate consultations. Areas in need of improvement common to these major applications include (1) increased compatibility and integration with established electronic medical record systems, (2) development of fully integrated billing capability, (3) simplifying user interface and allowing user-designed templates to communicate recommendations and patient education, and (4) reducing the cost of the applications. CONCLUSION: The four major S&F teledermatology applications in the United States are versatile applications capable of facilitating communication between referral and consultant sites. Continued efforts in making these applications more secure, robust, user-friendly, and affordable will contribute to wider implementation of

S&F teledermatology. Azzolini, C. (2011). "A pilot teleconsultation network for retinal diseases in ophthalmology." Journal of Telemedicine & Telecare 17(1): 20-24. A store-and-forward teleconsultation network was developed as a web application in order to provide second opinions on retinal diseases. The system provided automatic notification messages to the referring doctor and the consulted ophthalmologist by mobile phone message (SMS) and email. Images in the electronic medical record (EMR) could be examined in detail using special magnification software. Of the 19 ophthalmologists who agreed to participate, 17 used the teleconsultation network during the pilot trial (89%). During the fourweek study period, a total of 52 EMRs containing 82 images were uploaded by the participating ophthalmologists. In 46 cases (89%), a second opinion was provided by the consulted ophthalmologist. Thirty-three of the cases (72%) were related to macular diseases and anti-VEGF (vascular endothelial growth factor) ophthalmology drugs. At the end of the study period, 18 of the participating ophthalmologists evaluated the cases, using a three-point score (poor, good, very good) for Access, Acceptability, Image Quality and Medical Efficacy. Most cases were rated as very good or good for all four variables. Successful use of the network in future will depend on various technical, policy and human factors. The latter is particularly important and appropriate motivations need to be found in order to promote teleconsultations. Bas, M., J. I. Ten, et al. (2010). "Can information technology improve the performance of remote monitoring systems?" Telemedicine Journal & E-Health 16(9): 977-979. Despite some clinical, economic, and other qualitative advantages associated with remote cardiac device monitoring systems, one of the main challenges concerns the management of the out-of-hospital data. Manual updating of hospital databases with the data stored in the manufacturers' servers increases time requirements and may introduce mistakes in the entries. The use of communication standards such as Health Level 7 for data interchange could provide a safe and easy way to access patient and device information. The present study of 38 patients was carried out with the Carelink[REGISTERED] remote monitoring technology. A formal process for remote cardiac device monitoring was established, including some features in the Arrhythmias Information System: mobile phone and e-mail were included for communication between patients and hospital, with a new gateway for automatic message sending. Device reports generated through the manufacturer's application were attached to the patient's record. Once the information concerning the transmission session was reviewed, the physician made a medical report, which was sent via post and e-mail to the patient. A new interface was created for Health Level 7 communication with the manufacturers' applications, so that the Arrhythmias Information System could automatically interchange information concerning the device and/or the patient when this kind of communication system is available. The volume of data generated by system warning alerts and transmission sessions makes it very difficult to meet the hospital database

updating requirements. Standard-based communication between hospital and manufacturers' applications is fundamental to automatic and reliable update of data. Baumeister, T., W. Weistenhofer, et al. (2009). "Prevention of work-related skin diseases: teledermatology as an alternative approach in occupational screenings." Contact Dermatitis 61(4): 224-230. BACKGROUND: Prevention of occupational skin diseases is of high socioeconomic impact. Implementing teledermatology into preventive occupational screenings holds obvious advantages; nevertheless, studies concerning this subject are scarce. OBJECTIVES: The present cross-sectional study was aimed at determining if results of a teledermatological examination are equally sensitive and specific at detecting minimal skin lesions as the conventional face-to-face examination. METHODS: The skin condition of the hands of 100 male wet workers was assessed in a face-to-face examination and a tele-examination by means of a score for minimal skin lesions. RESULTS: The comparison of the total score values that each participant received in face-to-face examination with those obtained in tele-examination proved the skin condition to be estimated significantly worse when seen in tele-examination (P < 0.0001). The median values of the sum totals and the median values for secondary lesions were higher in the tele-examination than in the face-to-face examination. CONCLUSIONS: Our findings show a tendency in tele-examination to assess the skin condition more critically in comparison with face-to-face examination. The teledermatological examination is sufficiently sensitive in detecting early signs of hand eczema, whereas signs for chronicity may get overestimated. Bergmo, T. S. (2010). "Economic evaluation in telemedicine - still room for improvement." Journal of Telemedicine & Telecare 16(5): 229-231. It has been reported that economic evaluations of telemedicine are less adherent to methodological standards than economic evaluations in other fields. Systematic reviews also show that most studies evaluate benefits in terms of the cost savings, with no assessment of the health benefits for patients. In a recent review of economic evaluations, I found 33 articles that measured both costs and non-resource consequences of using telemedicine in direct patient care. This represents a considerable increase compared to previous reviews. The articles analysed were highly diverse in both study context and applied methods. Most studies used multiple outcome measures, such as diagnostic accuracy, blood glucose levels, wound size or quality-adjusted life-years gained. The effectiveness measures appeared more consistent and well reported than the costings. Objectives, study design and choice of comparators were mostly well reported. However, most studies lacked information on perspective and costing method, few used general statistics and sensitivity analysis to assess validity, and even fewer used marginal analysis. These shortcomings in economic evaluation methodology are relatively common and have been found in other fields of research.

Bitterman, N. (2011). "Design of medical devices--a home perspective." European Journal of Internal Medicine 22(1): 39-42. Health care services are moving out to the community and into the home; ehealth services, remote monitoring technology and self-management are replacing hospitalization and visits to medical clinics and custom-tailored medicines are making inroads into normative treatment. These developments have great implications for the scope and design of home health care equipment. The paper discusses the unique nature of home medical devices, from a humanenvironment-machine perspective, focusing on the nature of users, environment and tasks performed. We call for increased awareness and active continuous involvement of health care personnel together with bioengineers, human factors experts, architects, designers and end users--patients and caregivers--in defining the objectives of health care devices and services at home in terms of "all family" use, integrated into the overall surroundings ("smart home"), and as part of a collaborative patient-physician disease management team. Copyright Copyright 2010 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. Blank, E., C. Lappan, et al. (2011). "Early analysis of the United States Army's telemedicine orthopaedic consultation program." Journal of Surgical Orthopaedic Advances 20(1): 50-55. Telemedicine is a recent development, designed to assist patients with limited physical access to expert subspecialty medical care. The United States Army has established a telemedicine program, consisting of e-mail consultations from deployed health care providers to subspecialty consultants. Orthopaedic surgery became a participating consultant group in July 2007. The goal of this study is to describe the Army's telemedicine orthopaedic program and to review its progress and achievements. All consults initiated from July 2007 through April 2009 were reviewed. A total of 208 consults were received by the telemedicine orthopaedic consultation program. Predominant regions of origin were Iraq, Navy Afloat, and Afghanistan. The Army accounted for the majority of consults. Prevalent musculoskeletal complaints were fracture, sprain, neuropathy, and tendon injury. Of the 74 fracture consultations, hand and wrist fractures were most common. Symptomatic treatment or casting/splinting were the most common recommended treatments for all orthopaedic consults. Of the 170 consults requesting specific treatment recommendations for patients who likely otherwise would have been evacuated for further evaluation, surgical intervention or medical evacuation was only recommended in 25% and 16% of the consultations, respectively. The novel Army telemedicine orthopaedic consultation program developed for combat-deployed service members provides expert treatment recommendations for a variety of musculoskeletal injuries. Deployed health care providers located in austere combat environments can better determine both the necessity of medical evacuation and appropriate treatments for service members with musculoskeletal injuries when aided by orthopaedic surgery consultants, thereby limiting the number of unnecessary medical evacuations.

Blozik, E., C. Sommer-Meyer, et al. (2011). "Effectiveness and safety of telemedical management in uncomplicated urinary tract infections." Journal of Telemedicine & Telecare 17(2): 78-82. Uncomplicated urinary tract infections (UUTI) in women are frequent reasons for consultations in general practice. We evaluated the effectiveness and safety of telemedical management at a telemedicine centre in Switzerland. Management followed evidence-based protocols, including teleprescription of an antibiotic. Consecutive UUTI patients who had a teleconsultation including the prescription of an antibiotic were followed up three days later about symptom relief, adverse events or the need to visit a doctor. Of a total of 526 eligible women, follow-up information was available for 95%. Three days after teleconsultation, 79% of patients reported complete symptom relief, and 92% reported a reduction of UUTI symptoms. Five percent of patients reported deterioration, e.g. due to an increase of pain, flank pain or fever. Four percent reported side-effects of the prescribed antibiotics. In the three days following teleconsultation, 4% of women consulted another health-care provider without further contacting the telemedicine centre. Another 8% of patients were referred to face-to-face consultation because they developed additional symptoms or because bacterial resistance of the prescribed antibiotic was suspected. Compared to data from the literature on UUTI, evidence-based telemedical management including teleprescription of an antibiotic is as safe and effective as prescriptions initiated by a face-to-face consultation. Bonnardot, L. and R. Rainis (2009). "Store-and-forward telemedicine for doctors working in remote areas." Journal of Telemedicine & Telecare 15(1): 1-6. For doctors working in remote areas, access to medical specialists is crucial in order to provide patients with the best possible health care. Telemedicine is now widely used to obtain second opinions from consultants and is a mainstay of the organization of health care in Antarctica. Taking advantage of our extreme geographical isolation on a polar station, we tested the possibilities for obtaining specialist advice by telemedicine based on email. Two virtual case reports with one question each were sent to six correspondents: two non-governmental organizations (NGOs), two personal acquaintances and two institutions. Initial email replies were received between 13 hours and 7 days later. There were three kinds of reply: well argued and well adapted to our situation (one NGO); argued but not well adapted to our situation (one NGO, one acquaintance and one institution); and a short reply without argument (one acquaintance). Contacting personal acquaintances was not as reliable as we had expected. The best support was provided by one of the NGOs whose efficiency was based on the use of an automatic message-handling system and a team of specialists well trained in giving advice to isolated doctors. This NGO demonstrated how a storeand-forward telemedicine system can be efficient and reliable; the study also highlighted some limitations in other methods of obtaining specialist advice. Bowling, F. L., L. King, et al. (2011). "Remote assessment of diabetic foot ulcers using a

novel wound imaging system." Wound Repair & Regeneration 19(1): 25-30. Telemedicine allows experts to assess patients in remote locations, enabling quality convenient, cost-effective care. To help assess foot wounds remotely, we investigated the reliability of a novel optical imaging system employing a threedimensional camera and disposable optical marker. We first examined inter- and intraoperator measurement variability (correlation coefficient) of five clinicians examining three different wounds. Then, to assess of the system's ability to identify key clinically relevant features, we had two clinicians evaluate 20 different wounds at two centers, recording observations on a standardized form. Three other clinicians recorded their observations using only the corresponding three-dimensional images. Using the in-person assessment as the criterion standard, we assessed concordance of the remote with in-person assessments. Measurement variation of area was 3.3% for intraoperator and 11.9% for interoperator; difference in clinician opinion about wound boundary location was significant. Overall agreement for remote vs. in-person assessments was good, but was lowest on the subjective clinical assessments, e.g., value of debridement to improve healing. Limitations of imaging included inability to show certain characteristics, e.g., moistness or exudation. Clinicians gave positive feedback on visual fidelity. This pilot study showed that a clinician viewing only the threedimensional images could accurately measure and assess a diabetic foot wound remotely. Copyright 2010 by the Wound Healing Society. Brewer, R., G. Goble, et al. (2011). "A peach of a telehealth program: Georgia connects rural communities to better healthcare." Perspectives in Health Information Management 8: 1c. This article presents Georgia's telehealth response to some of the significant healthcare challenges and disparities facing the rural citizens of this state. When compared to their urban and suburban counterparts, rural communities have fewer healthcare providers, and residents must travel longer distances to reach them. Georgia's statewide telemedicine network, the Georgia Partnership for TeleHealth (GPT), uses information technology to improve the efficiency and quality of healthcare and health outcomes for underserved populations in Georgia. Buckley, K. M., L. K. Adelson, et al. (2009). "Reducing the risks of wound consultation: adding digital images to verbal reports." Journal of Wound, Ostomy, & Continence Nursing 36(2): 163-170. PURPOSE: The purpose of this study was to examine the impact of digital images on the assessment and recommendations of a WOC nurse who was providing remote nurse-to-nurse consultations on home care patients with wounds. METHODS: In a descriptive comparative study, data were collected by home care nurses from a sample of 43 adult patients with a total of 89 wounds with various etiologies. To determine whether or not the addition of a digital photograph influenced the WOC nurse's assessment and recommendations, the WOC nurse first completed a wound assessment and recommendation form based on a verbal report from the home care nurse. The WOC nurse then

accessed digital images of the wounds and made any indicated modifications to the original assessment and management plan, providing a rationale for any changes. Comparisons were made between the assessment completed by the home care nurse and the WOC nurse's assessment and between the WOC nurse's assessment and recommendations based only on a verbal report and his or her assessment and recommendations based on the combination of a verbal report and a digital photograph. RESULTS: Although there was a high percentage of agreement between the wound assessments completed by the home care nurse and those completed by the WOC nurse, areas of disagreement often impacted on the overall assessment. The agreement rates between the WOC nurse's assessment and recommendations based only on a verbal report versus those based on a combination of verbal report and digital photographs were as follows: total agreement (26/89 = 29.2%), trivial disagreement (11/89 = 12.4%), and clinically relevant disagreement (52/89 = 58.4%). CONCLUSIONS: WOC nurses who provide remote nurse-to-nurse consultations without directly visualizing the patients' wounds through digital images are at risk for under-or overtreating patients' wounds. Digital images also provide an opportunity for the WOC nurse to mentor home care nurses in wound assessment and care. Bulik, R. J. (2008). "Human factors in primary care telemedicine encounters." Journal of Telemedicine & Telecare 14(4): 169-172. Traditional delivery of primary care takes place in a face-to-face transaction between provider and patient. In telemedicine, however, the transaction is 'filtered' by the distance and technology. The potential problem of filtered communication in a telemedicine encounter was examined from a human factors perspective. Patients with and without experience of telemedicine, and providers who had experience of telemedicine, were asked about patient-provider relationships in interviews and focus groups. Seven themes emerged: initial impressions, style of questions, field of view, physical interaction, social talk, control of encounter and ancillary services. This suggests that communication can be improved and better patient-provider relationships can be developed in a primary care telemedicine encounter if attention is paid to four areas of the interaction: verbal, non-verbal, relational and actions/transactional. The human factors dimension of telemedicine is an important element in delivery of health care at a distance - and is one of few factors over which the provider has direct control. Burke, B., Jr., A. Bynum, et al. (2008). "Rural school-based telehealth: how to make it happen." Clinical Pediatrics 47(9): 926-929. When organizing new health care interventions among a rural population, a careful planning process respecting community-specific considerations should be used. The project objective centered on the successful implementation of a school-based telehealth clinic serving a rural, health-disparate population. Using an American Academy of Pediatrics Community Access to Child Health planning grant, a needs assessment of the Delta community was conducted. In

synthesizing the results of this planning project, consensually addressed issues led to establishing a pilot school-based telehealth clinic within the rural county schools. Seven essential steps emerged as a set of guidelines that entities might consider in introducing a telemedicine school-based service in a rural community. The steps included assessing local and regional needs, securing community support and establishing goals, evaluating resources, configuring logistics, training staff, informing parents, and launching the clinic. Proper planning is crucial to the establishment of a rural school-based telehealth clinic. Cabana, F., P. Boissy, et al. (2010). "Interrater agreement between telerehabilitation and face-to-face clinical outcome measurements for total knee arthroplasty." Telemedicine Journal & E-Health 16(3): 293-298. Outcome measures in physical therapy provide the basis for determining the patient's rehabilitation needs, developing an individual intervention plan, and reassessing the evolution of the condition after therapeutic intervention. Questions surrounding the validity and reliability of outcome measures obtained in the context of telerehabilitation remain. The goal of this study was to explore which outcome measures can be used reliably in the context of telerehabilitation after discharge from an acute care hospital for lower limb orthopedic surgery. Fifteen patients recently discharged after total knee arthroplasty were evaluated by two experienced therapists. Each therapist evaluated under a given condition (face-to-face assessment, telerehabilitation assessment) eight outcome measures taken from standard clinical tests routinely used in the management of orthopedic rehabilitation after total knee arthroplasty. Evaluations were measured at 1-day intervals. Telerehabilitation evaluations were conducted with a videoconference link (H.264 CoDecs with Pan, Tilt, Zoom cameras) between either the participant's home or a clinical environment and a remote clinical station over residential DSL lines at 512 kbps. Interrater agreement between the two measurement modes was analyzed using the Bland and Altman method and Kripendorff's alpha reliability estimate. The 95% confidence interval for mean difference between evaluation methods varied between -20% and 8% for knee range of motion measures, -85% and 55% for scar management, -33% and 29% for functional evaluations. Five out of the eight outcome measures showed reliability estimates of >0.80, with lowest reliability obtained for the scar assessment scale (0.34) and the highest reliability for the evaluation of the range of motion at the knee (0.87 in flexion and 0.85 in extension). Clinical variables typically measured in face-to-face evaluations can be measured successfully under telerehabilitation conditions with moderate reliability. Caffery, L. J. and A. C. Smith (2010). "A transmission security framework for emailbased telemedicine." Studies in Health Technology & Informatics 161: 35-48. Encryption is used to convert an email message to an unreadable format thereby securing patient privacy during the transmission of the message across the Internet. Two available means of encryption are: public key infrastructure (PKI) used in conjunction with ordinary email and secure hypertext transfer protocol (HTTPS) used by secure web-mail applications. Both of these approaches have

advantages and disadvantages in terms of viability, cost, usability and compliance. The aim of this study was develop an instrument to identify the most appropriate means of encrypting email communication for telemedicine. A multimethod approach was used to construct the instrument. Technical assessment and existing bodies of knowledge regarding the utility of PKI were analyzed, along with survey results from users of Queensland Health's Child and Youth Mental Health Service secure web-mail service. The resultant decision support model identified that the following conditions affect the choice of encryption technology: correspondent's risk perception, correspondent's identification to the security afforded by encryption, email-client used by correspondents, the tolerance to human error and the availability of technical resources. A decision support model is presented as a flow chart to identify the most appropriate encryption for a specific email-based telemedicine service. Capampangan, D. J., K. E. Wellik, et al. (2009). "Telemedicine versus telephone for remote emergency stroke consultations: a critically appraised topic." Neurologist 15(3): 163-166. BACKGROUND: The rate of patients being treated with thrombolytic therapy is low, in part, due to a shortage of vascular neurologists, especially in rural communities. Two-way audio-video communication through telemedicine has been demonstrated to be a reliable method to assess neurologic deficits due to stroke and maybe more efficacious in determining thrombolytic therapy eligibility than telephone-only consultation. OBJECTIVE: To determine the efficacy of telemedicine versus telephone-only consultations for decision making in acute stroke situations. METHODS: The objective was addressed through the development of a structured, critically appraised topic. Participants included consultant and resident neurologists, clinical epidemiologists, medical librarian, and clinical content experts in the fields of vascular neurology, emergency medicine, and telemedicine. Participants started with a clinical scenario and a structured question, devised search strategies, located and compiled the best evidence, performed a critical appraisal, synthesized the results, summarized the evidence, provided commentary, and declared bottom-line conclusions. RESULTS: : A single randomized, blinded, prospective trial comparing telephone-only consultations to telemedicine consultations for acute stroke was selected and appraised. Correct acute stroke treatment decisions were made more often in the telemedicine group versus the telephone-only group (98% vs. 82%, [number needed to assess = 6]). Stroke telemedicine when compared with telephone-only consultations was more sensitive (100% vs. 58%), more specific (98% vs. 92%), had a more favorable positive likelihood ratio (LR: 41 vs. 7) and negative likelihood ratio (LR: 0 vs. 0.5), and had higher predictive values (positive predictive value 94% vs. 76%, and negative predictive value 100% vs. 84%) for the determination of thrombolysis eligibility. CONCLUSION: Stroke telemedicine when compared with telephone-only consultations is an effective method to determine thrombolysis eligibility for acute stroke patients who do not have immediate access to a stroke neurologist.

Capozzi, D. and G. Lanzola (2011). "Utilizing information technologies for lifelong monitoring in diabetes patients." Journal of Diabetes Science & Technology 5(1): 55-62. BACKGROUND: Information and communication technologies have long been acknowledged to support information sharing along the whole chain of care, from the clinic to the homes of patients and their relatives. Thus they are increasingly being considered for improving the delivery of health care services also in light of clinical and technological achievements that propose new treatments requiring a tighter interaction among patients and physicians. METHODS: The multiagent paradigm has been utilized within an architecture for delivering telemedicine services to chronic outpatients at their domiciles and enforcing cooperation among patients, caregivers, and different members of the health care staff. The architecture sees each communication device such as a palmtop, smart phone, or personal digital assistant as a separate agent upon which different services are deployed, including telemetry, reminders, notifications, and alarms. Decoupling services from agents account for a highly configurable environment applicable to almost any context that can be customized as needed. RESULTS: The architecture has been used for designing and implementing a prototypical software infrastructure, called LifePhone, that runs on several communication devices. A basic set of services has been devised with which we were able to configure two different applications that address long-term and short-term monitoring scenarios for diabetes patients. The long-term scenario encompasses telemetry and reminder services for patients undergoing peritoneal dialysis, which is a treatment for chronic renal failure, a diabetes complication. The shortterm scenario incorporates telemetry and remote alarms and is applicable for training patients to use an artificial pancreas. CONCLUSIONS: Our experiments proved that an infrastructure such as LifePhone can be used successfully for bridging the interaction gap that exists among all the components of a health care delivery process, improving the quality of service and possibly reducing the overall costs of health care. Furthermore, the modularity of services allows for more complex scenarios encompassing data analysis or even involving actors at multiple institutions in order to better support the overall health care organization. Copyright 2010 Diabetes Technology Society. Chen, T. S., M. E. Goldyne, et al. (2010). "Pediatric teledermatology: observations based on 429 consults." Journal of the American Academy of Dermatology 62(1): 61-66. BACKGROUND: Store-and-forward teledermatology is an emerging means of access for patients with skin disease lacking direct access to dermatologists. OBJECTIVES: We sought to examine the patient demographics, diagnostic concordance, and treatment patterns in teledermatology for patients younger than 13 years. METHODS: We conducted a descriptive retrospective cohort study involving 429 patients. RESULTS: Diagnoses were concordant in 48% of cases, partially concordant in 10%, and discordant in 42%. Management recommendations were concordant in 28% of cases, partially concordant in 36%, and discordant in 36%. Primary care providers tended to underuse topical steroids and overuse topical antifungals and systemic antibiotics. Only 1.4% and 6.0% of patients required repeated teledermatology consultation and in-person

dermatology consultation, respectively. LIMITATIONS: Limitations were the inability to generalize the data from the population studied and the chances of error and bias in teledermatology diagnoses. CONCLUSIONS: Store-and-forward teledermatology can improve diagnostic and therapeutic care for skin disease in children who lack direct access to dermatologists. Christensen, H., K. M. Griffiths, et al. (2010). "Protocol for a randomised controlled trial investigating the effectiveness of an online e health application for the prevention of Generalised Anxiety Disorder." BMC Psychiatry 10: 25. BACKGROUND: Generalised Anxiety Disorder (GAD) is a highly prevalent psychiatric disorder. Effective prevention in young adulthood has the potential to reduce the prevalence of the disorder, to reduce disability and lower the costs of the disorder to the community. The present trial (the WebGAD trial) aims to evaluate the effectiveness of an evidence-based online prevention website for GAD. METHODS/DESIGN: The principal clinical question under investigation is the effectiveness of an online GAD intervention (E-couch) using a communitybased sample. We examine whether the effect of the intervention can be maximised by either human support, in the form of telephone calls, or by automated support through emails. The primary outcome will be a reduction in symptoms on the GAD-7 in the active arms relative to the non active intervention arms. DISCUSSION: The WebGAD trial will be the first to evaluate the use of an internet-based cognitive behavioural therapy (CBT) program contrasted with a credible control condition for the prevention of GAD and the first formal RCT evaluation of a web-based program for GAD using community recruitment. In general, internet-based CBT programs have been shown to be effective for the treatment of other anxiety disorders such as Post Traumatic Stress Disorder, Social Phobia, Panic Disorder and stress in clinical trials; however there is no evidence for the use of internet CBT in the prevention of GAD. Given the severe shortage of therapists identified in Australia and overseas, and the low rates of treatment seeking in those with a mental illness, the successful implementation of this protocol has important practical outcomes. If found to be effective, WebGAD will provide those experiencing GAD with an easily accessible, free, evidence-based prevention tool which can be promoted and disseminated immediately. Clark, P. A., K. Capuzzi, et al. (2010). "Telemedicine: medical, legal and ethical perspectives." Medical Science Monitor 16(12): RA261-272. Technological innovations in medical care have led to the development of telemedicine programs in both rural and urban environments. The necessity for telemedicine has increased immensely as more cost-effective treatment options have become available for both patients and physicians through the addition of telecommunication technologies to medical practice. The development of telemedicine systems began as a means of providing access to health care resources for individuals living in isolated rural areas, grew into advanced medical intervention techniques for soldiers on the battlefield, and have become prevalent in urban medical centers both as a resource to the underserved

populations and as a platform for physicians off-site to conduct patient consults remotely. Urban telemedicine systems, as monitored in the Mercy Health System (Philadelphia, Pennsylvania) and AtlantiCare Regional Medical Center (Atlantic City, New Jersey), display the enormous benefits of telemedicine as a form of preliminary analysis of patients for the treatment of various medical conditions including chronic disease, mental health disorders and stroke. However, the initiation of telemedicine programs requires new protocols and safeguards to be initiated to protect patient confidentiality/privacy, ensure the appropriate licensure of physicians practicing across state borders, and educate patients on the use of new technological systems. Telemedicine represents the progression of medicine in the presence of improving communication technologies and should be instituted in all urban medical centers. This conclusion is based upon the ethical responsibility to treat all persons with dignity and respect, which in this case, mandates the provision of the most cost-effective, beneficial medical care for all populations. Coleman, J. R. (2002). "HMOs and the future of telemedicine and telehealth. Part 1." Case Manager 13(3): 36-40. the author reported that there are effeciencies using telemedicine. he reported that there was a lack of confirmation for cost saving. Coye, M. J., A. Haselkorn, et al. (2009). "Remote patient management: technologyenabled innovation and evolving business models for chronic disease care.[Erratum appears in Health Aff (Millwood). 2009 Jan-Feb;28(1) doi: 10.1377/hlthaff.28.1.126]." Health Affairs 28(1): 126-135. Remote patient management (RPM) is a transformative technology that improves chronic care management while reducing net spending for chronic disease. Broadly deployed within the Veterans Health Administration and in many small trials elsewhere, RPM has been shown to support patient self-management, shift responsibilities to non-clinical providers, and reduce the use of emergency department and hospital services. Because transformative technologies offer major opportunities to advance national goals of improved quality and efficiency in health care, it is important to understand their evolution, the experiences of early adopters, and the business models that may support their deployment. Dabiri, F., T. Massey, et al. (2009). "A telehealth architecture for networked embedded systems: a case study in in vivo health monitoring." IEEE Transactions on Information Technology in Biomedicine 13(3): 351-359. The improvement in processor performance through continuous breakthroughs in transistor technology has resulted in the proliferation of lightweight embedded systems. Advances in wireless technology and embedded systems have enabled remote healthcare and telemedicine. While medical examinations could previously extract only localized symptoms through snapshots, now continuous monitoring can discretely analyze how a patient's lifestyle affects his/her physiological conditions and if additional symptoms occur under various stimuli. We demonstrate how medical applications in particular benefit from a hierarchical

networking scheme that will improve the quantity and quality of ubiquitous data collection. Our Telehealth networking infrastructure provides flexibility in terms of functionality and the type of applications that it supports. We specifically present a case study that demonstrates the effectiveness of our networked embedded infrastructure in an in vivo pressure application. Experimental results of the in vivo system demonstrate how it can wirelessly transmit pressure readings measuring from 0 to 1.5 lbf/in (2) with an accuracy of 0.02 lbf/in (2). The challenges in biocompatible packaging, transducer drift, power management, and in vivo signal transmission are also discussed. This research brings researchers a step closer to continuous, real-time systemic monitoring that will allow one to analyze the dynamic human physiology. Dang, S., S. Dimmick, et al. (2009). "Evaluating the evidence base for the use of home telehealth remote monitoring in elderly with heart failure." Telemedicine Journal & EHealth 15(8): 783-796. Information and communication technology offers promise for better coordination of care for patients with congestive heart failure (CHF). MEDLINE, EMBASE, and CINHAL databases were searched for evidence on remote monitoring of patients with heart failure (HF). The search was restricted to randomized controlled trials using either automated monitoring of signs and symptoms or automated physiologic monitoring. For this review, telephone-based monitoring of signs and symptoms was not considered remote monitoring. Studies were also excluded if they did not present outcomes related to healthcare utilization. Nine studies met selection criteria, with interventions that varied greatly. Four three-arm studies directly compared the effectiveness of two different interventions to usual care. Six of the nine studies suggested a 27%-40% reduction in overall admissions. Two two-arm studies demonstrated a 40%-46% reduction in HF-related admissions while two other three-arm studies showed similar trends; however, this was not statistically significant. Three of nine studies suggested a significant reduction in mortality (30%-67%) and three studies showed significant reduction in healthcare utilization costs. Two studies suggested a 53%-62% reduction in bed days of care. Two studies showed significant reduction in the number of Emergency Department visits. Three two-arm studies and one three-arm study demonstrated significant overall improvement in outcomes with use of telemonitoring. Available data suggest that telemonitoring is a promising strategy. More data are needed to determine the ideal patient population, technology, and parameters, frequency and duration of telemonitoring, and the exact combination of case management and close monitoring that would assure consistent and improved outcomes with cost reductions in HF. [References: 45] Dansky, K. H. and J. Ajello (2005). "Marketing telehealth to align with strategy." Journal of Healthcare Management 50(1): 19-30; discussion 30-11. Telehealth is a twenty-first century solution to an old problem-how to deliver quality health services with shrinking resources. Telehealth enables healthcare providers to interact with and monitor patients remotely, thus adding value to service delivery models. On occasion, telehealth can substitute for live

encounters, saving time and resources. Furthermore, as the geriatric population increases, telehealth will support independent living by supplementing the existing network of care. To be used most effectively, however, telehealth services must be carefully planned and executed. This study investigated management practices used to promote telehealth services, focusing on strategic goals for adopting telehealth. Interviews with senior managers from 19 home health agencies identified three strategic goals for adopting telehealth: (1) clinical excellence, (2) technological preeminence, and (3) cost containment. Organizational documents were analyzed to determine the extent to which the telehealth program was featured in marketing materials. Documents included the organization's brochure, newspaper ads and articles, and each home health agency's web site. Results showed that marketing practices vary widely but are correlated with motivations to adopt telehealth. The organizations with the highest marketing scores emphasize clinical excellence as a major reason for using telehealth, whereas those with the lowest marketing scores tend to focus on cost containment. Although this study focused on management practices in home health agencies, results are applicable to hospital and outpatient services as well as to other community-based programs. Using a strategic management framework, the authors offer recommendations to help organizations develop effective marketing approaches for telehealth programs. Darkins, A., M.D., Ryan, P. , R.N., M.S., Kobb, R, M.N., A.P.R.N., Foster, L., M.S.N., R.N., Edmonson, E., R.N., M.P.H., Wakefield, B., Ph.D., R.N., and Lancaster, A.E., B.Sc. (2008). "Care Coordination/Home Telehealth:The Systematic Implementation of Health Informatics, Home Telehealth, and Disease Management to Support the Care of Veteran Patients with Chronic Conditions." TELEMEDICINE and e-HEALTH VOL. 14 NO. 10: 1118-1126. provide care to patients with chronic diseases on a far larger scale and shows it is a practical and cost-effective means of caring for populations Darkins, A., P. Ryan, et al. (2008). "Care Coordination/Home Telehealth: the systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic conditions." Telemedicine Journal & EHealth 14(10): 1118-1126. Between July 2003 and December 2007, the Veterans Health Administration (VHA) introduced a national home telehealth program, Care Coordination/Home Telehealth (CCHT). Its purpose was to coordinate the care of veteran patients with chronic conditions and avoid their unnecessary admission to long-term institutional care. Demographic changes in the veteran population necessitate VHA increase its noninstitutional care (NIC) services 100% above its 2007 level to provide care for 110,000 NIC patients by 2011. By 2011, CCHT will meet 50% of VHA's anticipated NIC provision. CCHT involves the systematic implementation of health informatics, home telehealth, and disease management technologies. It helps patients live independently at home. Between 2003 and 2007, the census figure (point prevalence) for VHA CCHT patients increased from 2,000 to 31,570 (1,500% growth). CCHT is now a routine NIC service

provided by VHA to support veteran patients with chronic conditions as they age. CCHT patients are predominantly male (95%) and aged 65 years or older. Strict criteria determine patient eligibility for enrollment into the program and VHA internally assesses how well its CCHT programs meet standardized clinical, technology, and managerial requirements. VHA has trained 5,000 staff to provide CCHT. Routine analysis of data obtained for quality and performance purposes from a cohort of 17,025 CCHT patients shows the benefits of a 25% reduction in numbers of bed days of care, 19% reduction in numbers of hospital admissions, and mean satisfaction score rating of 86% after enrolment into the program. The cost of CCHT is $1,600 per patient per annum, substantially less than other NIC programs and nursing home care. VHA's experience is that an enterprise-wide home telehealth implementation is an appropriate and cost-effective way of managing chronic care patients in both urban and rural settings. Dekio, I., E. Hanada, et al. (2010). "Usefulness and economic evaluation of ADSLbased live interactive teledermatology in areas with shortage of dermatologists." International Journal of Dermatology 49(11): 1272-1275. BACKGROUND: To overcome the problem of maldistribution of dermatologists in rural areas, live interactive teleconsultation systems are being used in some countries. However, these systems are not in common use because few evaluations on their efficiency and economic viability were reported. METHODS: We constructed an easy-to-use asymmetric digital subscriber line (ADSL)-based live interactive teleconsultation system and conducted 150 trial sessions between two rural hospitals and Shimane University Hospital. The clinical usefulness and economic advantages of this system were evaluated using data obtained from the trials. RESULTS: The system efficiently captured images at a resolution sufficient for specialized consultations: follicular openings were visible in the images obtained from a distance of 2 m. This system is more advantageous than a conventional clinic if the following condition is fulfilled: y <= 6.00 x-3.86 [x, time required for one-way travel (h); y, time required for consultation (h)]. Our two lines in trial fulfilled this condition. CONCLUSIONS: Asymmetric digital subscriber line-based live interactive teleconsultation technology is beneficial in many rural hospitals that do not have a dermatologist. Copyright 2010 The International Society of Dermatology. Demaerschalk, B. M. (2011). "Telemedicine or telephone consultation in patients with acute stroke." Current Neurology & Neuroscience Reports 11(1): 42-51. The advantages of telephone consultations for patients with acute stroke syndromes are history of use, simplicity, availability, portability, short consultation time, and facile implementation. The favorable aspects of telemedicine consultations are high accuracy, reliability, efficacy, and effectiveness, the growing technological sophistication of the offerings and features, and the high grade of recommendation. Between the two modalities, telemedicine is optimal for assessing patients with acute stroke and superior to telephone-only evaluations. Telephone consultations can serve as an adequate ancillary, adjunctive, supplemental, or back-up modality for a telestroke network. With

recent advances in one-way/two-way video and teleradiology features adapted to Smartphones, the dividing line between "telephone" and "telemedicine" consultations for acute stroke is indistinct. Telestroke providers prefer a figurative "tool belt" of technologies available to adapt to individual consultation requirements. Desai, B., K. McKoy, et al. (2010). "Overview of international teledermatology." The Pan African medical journal 6: 3. Teledermatology is essentially "dermatology at a distance", using one of many communication technologies to expand the reach of a dermatologist to those in need of their specialized knowledge. Most international teledermatology is storeand-forward in nature, a method in which images are stored on a computer and then transmitted electronically to a consulting dermatologist. This system is more convenient and less costly than real-time teledermatology. This review will focus on several of the store-and-forward teledermatology systems being developed and utilized successfully internationally. This discussion of "who" is practicing teledermatology is not comprehensive, but attempts to show some of the breadth of teledermatology practice around the world, including government national health plans, commercial endeavors, and charitable work by individuals and institutions. The goal in many instances is to provide better health outcomes through increased access, efficiency, and/or cost-effectiveness. More studies ultimately need to be conducted to develop a more comprehensive and sustainable model for teledermatology. Dinevski, D. and G. Pacnik (2009). "A novel approach to telemedicine video control technology." Telemedicine Journal & E-Health 15(9): 859-866. Telemedicine, especially teletrauma and telepresence, relies on live video streams, for optimal patient diagnosis and management, including assessment of diagnostic images such as plain x-ray, ultrasound, or other modalities. A pan-tiltzoom camera used in such cases should provide enough freedom of movement and a real sense of telepresence. Operating such cameras, especially in a critical situation, is time consuming, having to control multiple parameters one at a time to get the desired view on patient. In this article, we propose a novel approach to remote camera control for use in telemedicine. A method using a neural network for visual servo control is proposed. The system is based on two cameras: one for live visual feedback and the other for visual servoing of the robot arm to the desired location. The operator selects the location he wants to observe and the visual servo navigates a live feedback camera accordingly. Diver, A. J., H. Lewis, et al. (2009). "Telemedicine and trauma referrals--a plastic surgery pilot project." Ulster Medical Journal 78(2): 113-114. A pilot study of the use of digital images as an adjunct to telephone referral was undertaken. Hand trauma represented the majority of the twenty patients included in the study, and the system was found to be an effective aid to delivering appropriate management. We have found image analysis to be a useful addition to the telephone referral process already in use in our unit, but it

is unlikely to replace the need for real time clinical assessment of the patient. Edison, K. E., D. S. Ward, et al. (2008). "Diagnosis, diagnostic confidence, and management concordance in live-interactive and store-and-forward teledermatology compared to in-person examination." Telemedicine Journal & E-Health 14(9): 889-895. Teledermatology studies have examined diagnostic concordance between liveinteractive (LI) and in-person examinations (IP); and between store-and-forward (SF) and IP examinations. However, no studies have looked simultaneously across all three care delivery modalities, and few have measured management concordance and diagnostic confidence of the dermatologist. The purpose of this study was to compare LI and SF modalities with IP with respect to diagnostic and management concordance and to compare physician diagnostic confidence across the three modalities. Four dermatologists, in random rotation among all three care modalities, examined 110 new patients. Confidence was rated on a Likert scale from 1 to 5 (5 = total confidence; 1 = no confidence). Identical diagnoses were given to the patient by examiners from all three examination modalities in 70/110 patients (64%). More identical diagnoses were given for IP and LI examinations than for IP and SF examinations (80% vs. 73%); however, the difference was not statistically significant (p = 0.13). The highest self-reported confidence rating was given for 87% of IP examinations, 59% for LI, and 54% for SF. Diagnostic confidence ratings for SF and LI were not significantly different from each other (p = 0.50); however, diagnostic confidence ratings for LI and SF were both statistically lower than IP (p < 0.0001). Dermatologists were more confident with IP examination than either form of teledermatology. The percent of diagnostic and management agreement among IP, LI, and SF modalities was high. Ekeland, A. G., A. Bowes, et al. (2010). "Effectiveness of telemedicine: a systematic review of reviews." International Journal of Medical Informatics 79(11): 736-771. OBJECTIVES: To conduct a review of reviews on the impacts and costs of telemedicine services. METHODS: A review of systematic reviews of telemedicine interventions was conducted. Interventions included all e-health interventions, information and communication technologies for communication in health care, Internet based interventions for diagnosis and treatments, and social care if important part of health care and in collaboration with health care for patients with chronic conditions were considered relevant. Each potentially relevant systematic review was assessed in full text by one member of an external expert team, using a revised check list from EPOC (Cochrane Effective Practice and Organisation of Care Group) to assess quality. Qualitative analysis of the included reviews was informed by principles of realist review. RESULTS: In total 1593 titles/abstracts were identified. Following quality assessment, the review included 80 heterogeneous systematic reviews. Twenty-one reviews concluded that telemedicine is effective, 18 found that evidence is promising but incomplete and others that evidence is limited and inconsistent. Emerging themes are the particularly problematic nature of economic analyses of telemedicine, the benefits of telemedicine for patients, and telemedicine as

complex and ongoing collaborative achievements in unpredictable processes. CONCLUSIONS: The emergence of new topic areas in this dynamic field is notable and reviewers are starting to explore new questions beyond those of clinical and cost-effectiveness. Reviewers point to a continuing need for larger studies of telemedicine as controlled interventions, and more focus on patients' perspectives, economic analyses and on telemedicine innovations as complex processes and ongoing collaborative achievements. Formative assessments are emerging as an area of interest. Copyright Copyright 2010 Elsevier Ireland Ltd. All rights reserved. Elkaim, M., A. Rogier, et al. (2010). "Teleconsultation using multimedia messaging service for management plan in pediatric orthopaedics: a pilot study." Journal of Pediatric Orthopedics 30(3): 296-300. BACKGROUND: Application and assessment of the usefulness of image transfer through a mobile telephone in pediatric orthopaedic practice was investigated. METHODS: Twenty patients with traumatic lesions requiring urgent consultation were included. Relevant x-rays were photographed and transferred using Multimedia Messaging Service to the orthopaedic surgeon at our department. The discussion on the need to transfer the patient for treatment and the final treatment was retrospectively scrutinized by 10 independent orthopaedic surgeons. The agreement on the diagnosis and the management plan proposed after image transfer were assessed. RESULTS: The lesion concerned the lower limb in 6 cases, upper limbs in 13 cases, and the spine in 1 case in patients aged 2 to 16 years. The transmitted images were 160 x 120-pixel jpeg files in 1 case, 240 x 180-pixel jpeg files in 8 cases, 320 x 240-pixel jpeg files in 1 case, and 640 x 480-pixel jpeg files in 10 cases. In all the cases studied, all the investigators agreed that the images were good enough for doing the diagnosis even in cases of minor or nondisplaced fractures. The same decisions of transfer or management were taken in all the cases by all the investigators. Review of the transferred images versus the original full-scale images did not change the final diagnosis and management plan. CONCLUSIONS: In this study, even in case of low-resolution images (160 x 120-pixel jpeg), images were of sufficiently high quality for interpretation. This enables rational management decisions to be made using this costless and widely available technology. In patients requiring surgical treatment, a final operative decision is mandatory after transfer, bedside examination, and review of other data in addition to images. Teleconsultation using Multimedia Messaging Service is especially useful to improve remote management of orthopaedic patients in local hospitals or for decisions of transfer when surgical treatment is needed. CLINICAL RELEVANCE: Level IV (case series). Eminovic, N., N. F. de Keizer, et al. (2009). "Teledermatologic consultation and reduction in referrals to dermatologists: a cluster randomized controlled trial." Archives of Dermatology 145(5): 558-564. OBJECTIVE: To determine whether teledermatologic consultations can reduce referrals to a dermatologist by general practitioners (GPs). DESIGN: Multicenter

cluster randomized controlled trial. Setting and PARTICIPANTS: We recruited 85 GPs from 35 general practices in 2 regions in the Netherlands (Almere and Zeist); 5 dermatologists from 2 nonacademic hospitals were also included in the study. Interventions The GPs randomized to the intervention used a teledermatologic consultation system to confer with a dermatologist, whereas those in the control group referred their patients according to usual practice. All patients, regardless of their condition, were seen in the office by a dermatologist after approximately 1 month. OUTCOME MEASURES: The main outcome measure was the proportion of office visits prevented by teledermatologic consultation, as determined by dermatologists at approximately the 1-month office visit. The secondary outcome measure was patient satisfaction, measured using the Patient Satisfaction Questionnaire III developed by Ware et al. RESULTS: The 85 study GPs enrolled 631 patients (46 intervention GPs, 327 patients; 39 control GPs, 304 patients). The 5 dermatologists considered a consultation preventable for 39.0% of patients who received teledermatologic consultation and 18.3% of 169 control patients, a difference of 20.7% (95% confidence interval, 8.5%-32.9%). At the 1-month dermatologist visit, 20.0% of patients who received teledermatologic consultation had recovered compared with 4.1% of control patients. No significant differences in patient satisfaction were found between groups. CONCLUSIONS: Teledermatologic consultation offers the promise of reducing referrals to a dermatologist by 20.7%. Providing teledermatologic consultation by GPs with more extended knowledge of dermatology may further reduce the need for dermatologist referrals. Trial Registration Current Controlled Trials No. ISRCTN57478950. Ens, C. D. L., A. Hanlon-Dearman, et al. (2010). "Using telehealth for assessment of fetal alcohol spectrum disorder: the experience of two Canadian rural and remote communities." Telemedicine Journal & E-Health 16(8): 872-877. INTRODUCTION: Telehealth has been used for fetal alcohol spectrum disorder (FASD) diagnostic assessment in select Manitoban communities since 2000. OBJECTIVE: The purpose of this study was to evaluate the FASD telehealth program within two rural and remote Northern Manitoban communities by comparing community practices from the perspective of professionals working with the FASD diagnostic clinics in these communities. Recommendations for the further development of FASD assessment by telehealth were made to further improve current implementation and guide expansion of the FASD telehealth program within the province. METHODOLOGY: Semistructured interviews were conducted from October 19 to December 11, 2009. Participants (N = 26) were comprised of professionals, including those in the education, social services, and health sectors. RESULTS AND RECOMMENDATIONS: Two themes emerged from the data and covered the perceived strengths and drawbacks with the program, and meaningful suggestions to improve the service. Participants regarded the FASD telehealth program as successful and useful, especially given the remote location of the communities and the lack of on-site services. Recommendations addressing the barriers pertaining to the process were made from the study's findings and available scientific literature. CONCLUSIONS: This

study will provide a solid basis for the successful further development of the FASD telehealth programs. Fabbrocini, G., A. Balato, et al. (2008). "Telediagnosis and face-to-face diagnosis reliability for melanocytic and non-melanocytic 'pink' lesions." Journal of the European Academy of Dermatology & Venereology 22(2): 229-234. BACKGROUND: Telemedicine is a worldwide healthcare practice that, during the last years, has dramatically reduced the time of consultation for patients. Teledermoscopy aids in the current management of skin cancers in general and particularly of melanoma; telemedicine and teledermoscopy give the chance to provide consultations with experts also by long distance. OBJECTIVE: The purpose of this study is to determine the diagnostic reliability, according to interobserver agreement, between clinical and dermoscopic diagnosis of lesions with poor and/or absent pigmentation, comparing face-to-face diagnosis and telediagnosis. MATERIALS AND METHODS: Forty-four lesions were examined by two different dermatologists with good and similar experience in the clinical field and dermoscopy. A store-and-forward teledermatological system, based on clinical and dermoscopic images, was done by the two skilled dermatologists. RESULTS: Our results underline that teledermoscopy of 'pink' lesions does not provide a similar degree of diagnostic accuracy as otherwise in face-to-face diagnosis perhaps due to the absence of typical criteria. Atypical skin lesions are characterized by the absence of typical dermoscopic patterns, and their teleconsultation does not always increase the diagnostic accuracy. Farb, A., S. A. Brown, et al. (2010). "Interventional cardiology live case presentations: regulatory considerations." Catheterization & Cardiovascular Interventions 76(4): E126129. Live case presentations are increasingly common at interventional cardiology conferences. Taking advantage of significant advances in communication technology, broadcasts of procedures can be viewed as an extension of traditional medical education targeted to large groups of practitioners. However, there are important ethical, commercial, and patient safety issues associated with live cases that deserve attention. Use of investigational devices in live case demonstrations is subject to review and approval by FDA's Center for Devices and Radiological Health (CDRH), and the outcomes of patients participating in live cases are considered in the overall clinical study results. This article discusses CDRH's regulatory view of live case presentations with a focus on patient safety, clinical trial integrity, and concerns regarding improper medical device promotion. Copyright 2010 Wiley-Liss, Inc. Farber, N., J. Haik, et al. (2011). "Third generation cellular multimedia teleconsultations in plastic surgery." Journal of Telemedicine & Telecare 17(4): 199-202. We conducted a study to test whether new third generation (3G) mobile phones could be integrated into service as a working tool between plastic surgeons. During an eight-month period, 58 multimedia consultations were performed involving 57 patients. The majority of the consultations were for trauma or

wounds. All consultations comprised a digital photograph taken with the integrated camera and sent via the Multimedia Messaging Service (MMS). In 86% of the cases the residents reported that multimedia information contributed to their ability to independently handle similar cases in future. Satisfaction scores were high among all participants. We believe that a multimedia consultation in a hospital setting adds information to an ordinary telephone call, thus decreasing medico-legal risks. We recommend it for routine use. Ferrer-Roca, O., A. Garcia-Nogales, et al. (2010). "The impact of telemedicine on quality of life in rural areas: the Extremadura model of specialized care delivery." Telemedicine Journal & E-Health 16(2): 233-243. BACKGROUND: Referrals from rural health centers to urban hospitals join waiting lists as outpatients for hospital admission and hospital treatment. This influences quality of life (QoL) of the rural population and retired people who require medical attention without traveling, provided no risks are involved. For this reason, a rural region of Spain has adopted a strategy to deliver telemedicine (TM) specialized care (Extremadura model) as a political decision. OBJECTIVES: The present study aimed at objectively assessing QoL on aspects of health and well-being for citizens benefiting from this system. METHODS: We performed a randomized study of 800 primary care patients referred for specialized care: 420 regular face-to-face hospital referrals and 380 referred to a hospital specialist at a distance by TM. The study used two questionnaires: a modified version of the classical SF-12v2 short form questionnaire for health and well-being and a specific author-elaborated questionnaire. The latter focused on major patient concerns such as (1) discomfort and pain relief, (2) swift diagnosis, (3) swift treatment, (4) swift decision on hospital admission or not, (5) avoidance of traveling, (6) avoidance of red tape, and (7) personal attention. QoL was assessed twice: before referral to a hospital specialist and 6 months after referral to the same. The results were statistically compared. RESULTS: Both groups showed comparable health status with added advantages for TM referrals such as (1) less traveling (p = 0.0001) and (2) faster diagnosis, health examination, and treatment (p = 0.0001). CONCLUSION: Telemedicine care by a hospital specialist through videoconferencing was comparable to hospital referral for faceto-face medicine. Teleconsultations managed by nurses had a positive impact on the QoL of rural patients. They did not have to travel and thus diagnoses and examinations to start treatment were initiated faster. Foltynski, P., J. M. Wojcicki, et al. (2011). "Monitoring of diabetic foot syndrome treatment: some new perspectives." Artificial Organs 35(2): 176-182. Diabetic foot syndrome (DFS) is one of the major complications of diabetes, and it can lead to foot amputations. It is very important to assure good medical care for diabetic patients not only during their stay at hospital but also at home. Telecare can be one good solution for extending medical care to patients' homes. There are some reports regarding the application of new technologies in this field. The standard current model of telecare of DFS includes experts at hospital who conduct clinical examinations and decision making at a distance, in close

cooperation with a visiting nurse and the patient. In the present paper a new paradigm of the DFS's telecare is introduced, which eliminates the visiting nurse. The designed and developed TeleDiaFoS system consists of a traditional database and mobile patient's module (PM) allowing for documentation of the foot images as well as the results of blood glucose and blood pressure measurements taken by the patient himself at home. A 2-year validation of the TeleDiaFoS system on 10 DFS patients (3 months each) proved its usefulness and led to acceptance of this type of technical support by patients and physicians. The designed and developed system and proposed sterilization procedure of the PM have been found to be easy to use by the patient at home. Copyright 2010, Copyright the Authors. Artificial Organs Copyright 2010, International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc. Froehlich, W., S. Seitaboth, et al. (2009). "Case report: an example of international telemedicine success." Journal of Telemedicine & Telecare 15(4): 208-210. An 8-month old girl presented to the Angkor Hospital for Children in Siem Riep, Cambodia with fevers, bilateral eye discharge and an extensive body rash. The rash consisted of large, fluid-filled bullae and significant desquamation. The patient was admitted to the hospital and given intravenous cloxacillin for presumed bullous impetigo. Despite treatment with antibiotics, the skin lesions did not improve and the fevers continued. Telemedicine consultations were initiated by email between Angkor Hospital for Children and paediatric specialists in the USA. Several diagnoses were entertained throughout the subsequent collaborative dialogue. Ultimately, teleconsultation led to a diagnosis of chronic bullous dermatosis of childhood (CBDC), a rare sub-epidermal blistering disease. The child was started on appropriate medications. Within 24 hours, the lesions showed significant improvement and fevers resolved. By enabling advice from distant providers on diagnosis and treatment of paediatric patients, telemedicine may improve health care in developing countries. Fruhauf, J., G. Schwantzer, et al. (2010). "Pilot study using teledermatology to manage high-need patients with psoriasis." Archives of Dermatology 146(2): 200-201. paper showed how dermatologists were able to treat psoariasis better with the patient using smart phones to transmit exacerbations. Geoffroy, O., P. Acar, et al. (2008). "Videoconference pediatric and congenital cardiology consultations: a new application in telemedicine." Archives of cardiovascular diseases 101(2): 89-93. BACKGROUND: The relative rarity of congenital heart disease gives it an orphean disease status, requiring specialised centres. The present maturity of information technology allows telemedicine to be integrated into current medical practice. We report our experience of telemedicine between the cardiology department at St Pierre Hospital on the island of Reunion and the pediatric cardiology department at the teaching hospital in Toulouse. AIMS: The aims of

this work were to 1. verify the technical feasibility of transmitting echocardiographic images, 2. determine an optimal therapeutic strategy for each patient, and 3. deliver precise information live to patients and their families. METHODS: Five pediatric cardiology videoconference consultation sessions were transmitted between April 2006 and May 2007. The videoconference equipment, POLYCOM VSX 7000 (R), was used to relay information between the two centres, using six high-debit digital telephone lines, allowing a transfer rate of 384 kbits/s and an image frequency of 25 frames per second. The echocardiographic equipment at St Pierre Hospital was connected to the videoconference equipment by an S-VHS video output. The transmitted sources alternated between the echographic video output and the signal from a video camera, with continuous audio transmission. RESULTS: The telemedicine meeting was made up of three main elements: 1. a consultation with real-time echocardiographic acquisition and transmission, 2. a discussion between medical colleagues, and 3. a discussion with the family. Five videoconference consultation sessions were organised between April 2006 and May 2007. 22 patients were involved (median age 3 years, age range 7 days to 48 years). Heart disease was congenital in 20 patients, and acquired in 2 patients. The aim of the telemedicine consultation was to specify: 1. medical treatment in 7 patients, and 2. an indication for surgery or interventional catheterisation in 15 patients. There was no significant change in diagnosis, but in 2 patients with complex heart disease some anatomical clarifications were made. For 3 patients, the videoconference discussion was essential to get the extremely reticent families to accept the indication for surgery. CONCLUSION: This is the first experience in France of telemedicine consultation for pediatric and congenital cardiology. These videoconferences allowed patients in the south of Reunion to benefit from a specialist opinion on optimal therapeutic strategy, with no delay or need to travel a long distance. Germain, V., A. Marchand, et al. (2010). "Assessment of the therapeutic alliance in face-to-face or videoconference treatment for posttraumatic stress disorder." Cyberpsychology, behavior and social networking 13(1): 29-35. Telepsychotherapy is a cutting-edge intervention that shows great promise in the mental health care field. However, the possibility of developing a high-quality therapeutic alliance is often doubted when psychotherapy is provided remotely. This study assesses the development of a therapeutic alliance in individuals with posttraumatic stress disorder who were treated either by videoconference therapy or a face-to-face therapy. Forty-six participants with PTSD received cognitive behavioral therapy, 17 of them by videoconference and 29 in person. A variety of questionnaires evaluating the quality of the therapeutic relationship were administered at five different times during treatment. Each session was also assessed by the therapist and the participant immediately afterwards. The results indicate that a therapeutic alliance can develop very well in both treatment conditions and that there is no significant difference between the two. Certain clinical and practical implications are discussed.

Glassman, A. R., R. W. Beck, et al. (2009). "Comparison of optical coherence tomography in diabetic macular edema, with and without reading center manual grading from a clinical trials perspective." Investigative Ophthalmology & Visual Science 50(2): 560-566. PURPOSE: To analyze the value of reading center error correction in automated optical coherence tomography (OCT; Stratus; Carl Zeiss Meditec, Inc., Dublin, CA) retinal thickness measurements in eyes with diabetic macular edema (DME). METHODS: OCT scans (n=6522) obtained in seven Diabetic Retinopathy Clinical Research Network (DRCR.net) studies were analyzed. The reading center evaluated whether the automated center point measurement appeared correct, and when it did not, measured it manually with calipers. Center point standard deviation (SD) as a percentage of thickness, center point thickness, signal strength, and analysis confidence were evaluated for their association with an automated measurement error (manual measurement needed and exceeded 12% of automated thickness). Curves were constructed for each factor by plotting the error rate against the proportion of scans sent to the reading center. The impact of measurement error on interpretation of clinical trial results and statistical power was also assessed. RESULTS: SD was the best predictor of an automated measurement error. The other three variables did not augment the ability to predict an error using SD alone. Based on SD, an error rate of 5% or less could be achieved by sending only 33% of scans to the reading center (those with an SD >or= 5%). Correcting automated errors had no appreciable effect on the interpretation of results from a completed randomized trial and had little impact on a trial's statistical power. CONCLUSIONS: In DME clinical trials, the error involved with using automated Stratus OCT center point measurements is sufficiently small that results are not likely to be affected if scans are not routinely sent to a reading center, provided adequate quality control measures are in place. Gorton, M. (2008). "Welcome to the world of telehealth: physicians reaping significant benefits." Journal of Medical Practice Management 24(3): 147-150. With helthcare cost and red tape spinning out of control, telehealth companies have come up with a way to streamline patient access to physicians 24/7/365 while giving physicians more flexibility and a chance to supplement their income. This article demonstrates how telehealth companies, like TelaDoc, make it increasingly possible for physicians to diagnose routine, nonemergency medical problems via telephone, as well as recommend treatment and prescribe medication when necessary. This simple and efficient approach enhances the role of primary care physicians, supports the "medical home" model, and improves patient access to care. Telehealth services offer a simple alternative for patients who want to avoid unnecessary trips to the emergency department; cannot otherwise overcome barriers to care; need greater access to preventive care services; and need short-term prescription refills. Gray, L. C., O. R. Wright, et al. (2009). "Geriatric ward rounds by video conference: a solution for rural hospitals." Medical Journal of Australia 191(11-12): 605-608.

OBJECTIVE: To evaluate the acceptance and cost of a ward-based geriatric consultation service delivered via a mobile videoconferencing system. DESIGN AND SETTING: Prospective observational study conducted in the geriatric unit of Toowoomba Base Hospital, Queensland, comparing a specialist consultation service delivered by videoconference (VC) with a "traditional" in-person service. The VC system was established in January 2007 and evaluated over an 18month period. Patient satisfaction with the service was assessed by questionnaire during a 1-week period in September 2008. MAIN OUTCOME MEASURES: Hospital acceptance of the service; patient satisfaction with the service; comparative cost of providing in-person and VC-mediated consultations. RESULTS: Uptake of the service increased progressively throughout the study period. Patient acceptance levels were high. The cost of video consultations for a 12-patient ward round and case conference was less than the cost of in-person consultations if the total road distance travelled by the specialist (Brisbane to Toowoomba and back) was 125 km or longer. CONCLUSION: Consultations via VC are an acceptable alternative to in-person consultations, and are less expensive than in-person consultations for even modest distances travelled by the clinician. Greene, C. J., L. A. Morland, et al. (2010). "How does tele-mental health affect group therapy process? Secondary analysis of a noninferiority trial." Journal of Consulting & Clinical Psychology 78(5): 746-750. OBJECTIVE: Video teleconferencing (VTC) is used for mental health treatment delivery to geographically remote, underserved populations. However, few studies have examined how VTC affects individual or group psychotherapy processes. This study compares process variables such as therapeutic alliance and attrition among participants receiving anger management group therapy either through traditional face-to-face delivery or by VTC. METHOD: The current study represents secondary analyses of a randomized noninferiority trial (Morland et al., in press) in which clinical effectiveness of VTC delivery proved noninferior to in-person delivery. Participants were male veterans (N = 112) with posttraumatic stress disorder (PTSD) and moderate to severe anger problems. The present study examined potential differences in process variables, including therapeutic alliance, satisfaction, treatment credibility, attendance, homework completion, and attrition. RESULTS: No significant differences were found between the two modalities on most process variables. However, individuals in the VTC condition exhibited lower alliance with the group leader than those in the in-person condition. Mean self-leader alliance scores were 4.2 (SD = 0.8) and 4.5 (SD = 0.4), respectively, where 5 represents strongly agree and 4 represents agree with positive statements about the relationship, suggesting that participants in both conditions felt reasonably strong alliance in absolute terms. Individuals who had stronger alliance tended to have better anger outcomes, yet the effect was not strong enough to result in the VTC condition producing inferior aggregate outcomes. CONCLUSION: Our findings suggest that even if group psychotherapy via VTC differs in subtle ways from in-person delivery, VTC is a viable and effective means of delivering psychotherapy. Copyright 2010 APA, all

rights reserved. Grubaugh, A. L., G. D. Cain, et al. (2008). "Attitudes toward medical and mental health care delivered via telehealth applications among rural and urban primary care patients." Journal of Nervous & Mental Disease 196(2): 166-170. Adequate health care services are often not available in rural and remote areas, and this problem is expected to grow worse in the near future. "Telehealth" interventions represent a strategy for addressing access to care problems. We examined and compared attitudes toward medical and mental health care delivered via telehealth applications among adult rural (n = 112) and urban (n = 78) primary care patients. We also examined attitudes toward telehealth applications among a subset of patients with posttraumatic stress disorder (PTSD)--a group likely in need of specialized services. Both urban and rural patients were receptive to receiving medical and psychiatric services via telehealth. There were few meaningful differences across variables between urban and rural patients, and there were no meaningful differences by PTSD status. These findings support the feasibility of telehealth applications, particularly for rural patients who may not otherwise receive needed services. Gundim, R. S. and W. L. Chao (2011). "A graphical representation model for telemedicine and telehealth center sustainability." Telemedicine Journal & E-Health 17(3): 164-168. This study shows the creation of a graphical representation after the application of a questionnaire to evaluate the indicative factors of a sustainable telemedicine and telehealth center in Sao Paulo, Brazil. We categorized the factors into seven domain areas: institutional, functional, economic-financial, renewal, academicscientific, partnerships, and social welfare, which were plotted into a graphical representation. The developed graph was shown to be useful when used in the same institution over a long period and complemented with secondary information from publications, archives, and administrative documents to support the numerical indicators. Its use may contribute toward monitoring the factors that define telemedicine and telehealth center sustainability. When systematically applied, it may also be useful for identifying the specific characteristics of the telemedicine and telehealth center, to support its organizational development. Hagland, M. (2009). "When every second counts. Cutting-edge hospitals are leveraging telestroke programs so neurologists can intervene when a stroke hits." Healthcare Informatics 26(12): 31-33. Telestroke programs offer an innovative approach to optimizing the care of patients presenting with stroke symptoms. ClOs are working with clinician leaders to support the remote consults that are at the heart of telestroke programs. Telestroke programs can be a "win-win" for all stakeholders involved, especially the referring hospitals and teaching facilities. Hailey D, R. R., Ohinmaa A. (2002). "Systematic review of evidence for the benefits of telemedicine." J Telemed Telecare 8(suppl 1): 1-7.

A systematic review of telemedicine assessments based on searches of electronic databases between 1966 and December 2000 identified 66 scientifically credible studies that included comparison with a non-telemedicine alternative and that reported administrative changes, patient outcomes, or results of economic assessment. Thirty-seven of the studies (56%) suggested that telemedicine had advantages over the alternative approach, 24 (36%) also drew attention to some negative aspects or were unclear whether telemedicine had advantages and five (8%) found that the alternative approach had advantages over telemedicine. The most convincing evidence on the efficacy and effectiveness of telemedicine was given by some of the studies on teleradiology (especially neurosurgical applications), telemental health, transmission of echocardiographic images, teledermatology, home telecare and on some medical consultations. However, even in these applications, most of the available literature referred only to pilot projects and to short-term outcomes. Few papers considered the long-term or routine use of telemedicine. For several applications, including teleradiology, savings and sometimes clinical benefit were obtained through avoidance of travel and associated delays. Studies of home care and monitoring applications showed convincing evidence of benefit, while those on teledermatology indicated that there were cost disadvantages to health-care providers, although not to patients. Forty-four of the studies (67%) appeared to have potential to influence future decisions on the telemedicine application under consideration. However, a number of these had methodological limitations. Although useful clinical and economic outcomes data have been obtained for some telemedicine applications, good-quality studies are still scarce and the generalizability of most assessment findings is rather limited. Hall, K. (2011). "Telemedicine in the NHS: The benefits and costs of implementing telecare services." <http://www.computerweekly.com/>. the author looked at cost saving for copd in england. found that telemedicine saved 1.2m pounds from admissions since they were down 50% Handschu, R., M. Scibor, et al. (2008). "Telemedicine in acute stroke: remote videoexamination compared to simple telephone consultation." Journal of Neurology 255(11): 1792-1797. BACKGROUND: Telemedicine is increasingly being used in acute stroke care. Some of the first studies and network projects are already applying remote audiovisual communication for patient evaluation. Formerly the telephone was the method of choice to contact experts for case discussion. We compared remote video-examination and telephone consultation in acute stroke care. METHODS: Two district hospitals were linked to stroke centers in Northern Bavaria. Patients with symptoms suggestive of an acute stroke were included. Remote video examination (RVE) was provided by live audiovisual communication and access to brain images; telephone consultation (TC) was done via standard telephone using a structured interview. There was a weekly rotation of the two methods. Demographic data and other data concerning

process and quality of care as well as outcome 10 days after stroke were recorded and compared between the two groups. RESULTS: Within the study period 151 consultations were made in acute stroke patients (mean age 66.8 years). 77 patients were seen by RVE and 74 by TC. Total examination times were 49.8 min for RVE and 27.2 min for TC (p < 0.01). Patients were more frequently transferred to the stroke center after TC consultation (9.1 % vs. 14.9 %, p < 0.05) and had a higher mortality 10 days after stroke (6.8 % vs. 1.3 %, p < 0.05). Diagnosis made by TC had to be corrected more frequently (17.6 % vs. 7.1 %; p < 0.05). CONCLUSIONS: Creating a network improves stroke care by establishing cooperation between hospitals. Telephone consultation could be a simple method of telemedicine to support cooperation as it is easy and widely available. However, outcome parameters like mortality indicate that remote video examination is superior to TC. Therefore, full-scale audiovisual communication is recommended for remote consultation in acute stroke care. Harvey, S., G. Peterkin, et al. (2010). "Eleven years of experience with low-bandwidth telemedicine in a nurse-led rural clinic in Scotland." Journal of Telemedicine & Telecare 16(8): 417-421. A pilot trial of telemedicine in primary care began in the village of Letham in 1998. The service provided conventional consultations with the district nurse, plus teleconsultations with a general practitioner (GP) at the health centre in Forfar, a few km away. In the first year, the videoconferencing link was used by 14 patients, all aged over 65 years. The telemedicine service was judged to be successful and subsequently expanded to patients of any age. It was used for a wide range of health matters, including postnatal care, mental health problems, physical ailments, receiving test results and discussions with the doctor. During the 11-year study period, a total of 646 teleconsultations were conducted, a median rate of 65 per year. A qualitative evaluation of the service was conducted in 1999. Although the GPs involved expressed some reservations about the limited video quality, all three user groups were positive about the service. Nonetheless, the telemedicine service was not adopted as a routine method of health-care delivery by the NHS. To enable any telemedicine application to move from the pilot trial stage to routine service requires several things to happen at an organisational and contractual level. Ultimately an organizational decision about adoption is required, followed by appropriate mechanisms to enable diffusion. Heinzelmann, P. J., C. M. Williams, et al. (2005). "Clinical outcomes associated with telemedicine/telehealth." Telemedicine Journal & E-Health 11(3): 329-347. This paper is a comprehensive review and synthesis of the literature concerning clinical outcomes associated with various telemedicine applications. It starts out with a brief description of the findings reported by similar literature reviews already published. Subsequently, it proposes a conceptual model for assessing clinical outcomes based on Donabedian's formulation of the Medical Care Process. Accordingly, research findings are reported in terms of the relevant components of the medical care process, namely, diagnosis, clinical management, and clinical outcomes. Specific findings are organized according to

the designated clinical and diagnostic application. This is followed by a general report of studies dealing with patient satisfaction. [References: 163] Helck, A., M. Matzko, et al. (2009). "Interdisciplinary expert consultation via a teleradiology platform--influence on therapeutic decision-making and patient referral rates to an academic tertiary care center." Rofo: Fortschritte auf dem Gebiete der Rontgenstrahlen und der Nuklearmedizin 181(12): 1180-1184. In addition to teleradiological reporting as a nighthawking or a regular service, teleradiological communication can be used for interdisciplinary expert consultation. We intended to evaluate an interdisciplinary consultation system based on a teleradiology platform with regard to its impact on therapeutic decision-making, directed patient referrals to an academic tertiary care center and the economic benefit for the hospital providing the service. Therefore, consultations from five secondary care centers and consecutive admissions to an academic tertiary care center were prospectively evaluated over a time period of six months. A total of 69 interdisciplinary expert consultations were performed. In 54 % of the cases the patients were consecutively referred to the university hospital for further treatment. In all acutely life-threatening emergencies (n = 9), fast and focused treatment by referral to the academic tertiary care center was achieved (average time to treat 130 min). The admissions to the academic tertiary care center led to improved utilization of its facilities with additional revenue of more than 1,000000 euro p. a. An interdisciplinary expert consultation via a teleradiology platform enables fast and efficient expert care with improved and accelerated patient management and improved utilization of the service providing hospital. Hersh W, H. M., Wallace J, Kraemer D, Patterson and S. S. P, Greenlick MA. . (2002). "A systematic review of the efficacy of telemedicine for making diagnostic and management decisions." J Telemed Telecare 8: 197-209. technology was used to collect history and examination, both the specificity and sensitivity was preserved especially for cardiology and general medicine. Hicks, L. L., D. A. Fleming, et al. (2009). "The application of remote monitoring to improve health outcomes to a rural area." Telemedicine Journal & E-Health 15(7): 664671. The objective of this study was to evaluate the impact of remote monitoring home telehealth on client and provider satisfaction, clinical outcomes, and cost. The project design was a pragmatic evaluation of the technology in a real-world setting at an operational scale rather than a controlled clinical trial. Patients receiving monitoring were selected by the home health agency, and a random sample of other agency clients was selected for comparative purposes. Data were collected on additional costs and benefits associated with home telehealth monitoring. Quantitative and qualitative data suggest that when remote

monitoring telehealth technology was utilized in the home-care setting, both clients and providers were very satisfied with services; they felt it was easy to communicate, and that the technology was convenient and user friendly. Clients also felt that home telehealth technology had a very positive impact on the provider-client relationship and improved care. The study also suggests that home care monitoring reduces hospitalizations and decreases personnel expenses. This preliminary study provides evidence as to the value of remote monitoring home telehealth in the delivery of services to home care populations. It also provides evidence as to the positive impact that this form of technology may have on healthcare systems, provider and client satisfaction, and on the relationships that form between providers and clients. Hilty, D. M., H. C. Cobb, et al. (2008). "Telepsychiatry reduces geographic physician disparity in rural settings, but is it financially feasible because of reimbursement?" Psychiatric Clinics of North America 31(1): 85-94. Telemedicine has been shown to improve rural patient outcomes in two randomized controlled trials, to increase access to many patients, to serve underserved minorities, and to train primary care providers. Yet, programs are dwindling even after successful grants due to inadequate reimbursement. Studies have been thoroughly done to gauge the payor status of potential rural telemedicine patients, as the "floodgates" are not generally open to all-including those who cannot pay-in typical grants. Or the population of one community may not be representative of others. This study is part of a grant that explored the use of telemedicine for rural service delivery, attempted to get a clear snapshot of whom would be served if all were invited (paying or not), and to understand issues with the reimbursement systems. This article (1) examines the receipts of reimbursement and insurance coverage during the 1-year grant period by determining actual versus projected reimbursements, (2) identifies what payor(s) typical patients use, and (3) identifies problems and barriers for future study. Other administrative issues pertinent to telemedicine and costs are briefly discussed (eg, no-show rates, staffing, scheduling). Hoffman, K., Kennemer, K. "Telemedicine Reimbursement and Credentialing." a slide presentation on how Medicare reimburses telemedicine. Hoffmann, T., T. Russell, et al. (2008). "Using the Internet to assess activities of daily living and hand function in people with Parkinson's disease." Neurorehabilitation 23(3): 253-261. The ability to measure activities of daily living (ADL) and hand function for people with Parkinson's disease via an Internet-based telerehabilitation system would have a significant impact on the equity, accessibility, and management of the condition for patients who live in rural and remote communities. A low-bandwidth computer-based telerehabilitation system, which incorporates videoconferencing with calibrated assessment tools, has been recently developed at the University of Queensland. This study aimed to determine the validity, intra- and inter-rater reliability of the telerehabilitation system in measuring ADL and hand function in

12 people with Parkinson's disease. ADL status was assessed using the motor component of the Functional Independence Measure (FIM) and selected items from the Unified Parkinson's Disease Rating Scale (UPDRS). The Nine Hole Peg Test, Jamar dynamometer and Preston pinch gauge were also used to assess hand function. For half of the participants, an assessor administered assessments in the traditional face-to-face manner while another assessor simultaneously scored the same assessments via the telerehabilitation system. For the remaining participants, the telerehabilitation assessor administered the assessments via the telerehabilitation system while a face-to-face assessor simultaneously scored the assessments. The telerehabilitation system was found to be a valid measure of ADL status and hand function in people with Parkinson's disease and to have a high level of intra- and inter-rater reliability (all ICCs > 0.80). These results suggest that therapists can confidently use a low-bandwidth telerehabilitation system to assess ADL status and hand function in people with Parkinson's disease. Hoody, D., S. Hanson, et al. (2008). "Implementing a stroke system of care in a rural hospital: a case report from Granite Falls." Minnesota Medicine 91(10): 37-40. Acute stroke is a leading cause of morbidity and mortality. Both time-sensitive treatment and telemedicine are being used to improve the care of stroke patients in rural areas. This article highlights the case of a 62-year-old male patient with sudden onset of right-sided hemiparesis and a family history of vascular disease and how he was treated at a rural hospital that was connected by telemedicine technology to an urban tertiary care center. It also reviews protocols for acute treatment of stroke and systems of stroke care in rural areas. Jarad, N. A. and Z. M. Sund (2011). "Telemonitoring in chronic obstructive airway disease and adult patients with cystic fibrosis." Journal of Telemedicine & Telecare 17(3): 127-132. We compared the use of telemonitoring in patients with chronic obstructive pulmonary disease (COPD) and adult patients with cystic fibrosis (CF). Seventy patients (51 CF and 19 COPD) were enrolled in two studies of six months' duration. Patients used a personal data assistant (PDA) attached to a spirometer to score symptoms and to perform daily spirometry. Criteria for diagnosis of exacerbations of COPD and CF were pre-defined. When exacerbations were detected, patients were offered treatment according to a pre-designed protocol. Thirty-two (63%) CF patients and one (5%) COPD patient withdrew from the studies due to lack of adherence to daily recording. For those who remained in the study, COPD patients recorded more study days (139) than CF patients (113), P = 0.03. The median number of exacerbations detected during the study was greater in COPD than in CF patients, although this was not significant. The median number of device-detected exacerbations in the COPD group was significantly greater than in the CF group, P = 0.024. When compared to a parallel period in the previous year, the number of hospitalisations for COPD exacerbations was reduced, whereas the number of intravenous antibiotics in CF patients did not differ. Adherence to telemonitoring was much greater for COPD

than CF patients and the results appear to be more favourable for COPD patients than for CF patients. Jia, H., H.-C. Chuang, et al. (2009). "Long-term effect of home telehealth services on preventable hospitalization use." Journal of Rehabilitation Research & Development 46(5): 557-566. In this study, we assessed the longitudinal effect of a Department of Veterans Affairs (VA) patient-centered Care Coordination Home Telehealth (CCHT) program on preventable hospitalization use by veterans with diabetes mellitus (DM) at four VA medical centers. We used a matched treatment-control design (n = 387 for both groups). All patients were followed for 4 years. We operationalized ambulatory care-sensitive conditions (ACSCs) by applying Agency for Healthcare Research and Quality criteria to VA inpatient databases to determine preventable hospitalization use. We used a generalized linear mixed model to estimate the adjusted effect of the CCHT program on preventable hospitalization use over time. During the initial 18 months of follow-up, CCHT enrollees were less likely to be admitted for a preventable hospitalization than their nonenrollee counterparts, and this difference diminished during the rest of the 4-year follow-up period. The VA CCHT program for DM patients reduced preventable hospitalizations. These findings are some of the first that have systematically examined the extent to which home telehealth programs have a long-term effect on preventable hospitalization use. Joo, N.-S., Y.-W. Park, et al. (2010). "Cost-effectiveness of a community-based obesity control programme." Journal of Telemedicine & Telecare 16(2): 63-67. We evaluated two 12-week long community-based obesity control programmes in Korea. One was a visiting-type programme (V-type) (n = 515) administered by a public health centre and the other was a remote-type programme (R-type) (n = 410) utilizing an Internet website and mobile phones with a short message service. The total cost for the intention-to-treat subjects was US$116,993 in the V-type programme and $24,555 in the R-type programme. In the per-protocol subjects, 66% of V-type participants (n = 117) achieved the target bodyweight reduction (5%) and 13% of R-type participants (n = 15). In the per-protocol subjects, the cost per person was $227 (V-type) and $60 (R-type). The cost per person achieving the target weight reduction was $975 (V-type) and $1637 (Rtype). The average amount that participants were willing to pay was $71 (V-type) and $21 (R-type). The cost-effectiveness of the visiting-type community-based, short-duration obesity control programme was higher than the remote-type programme. Kaliyadan, F. and S. Venkitakrishnan (2009). "Teledermatology: clinical case profiles and practical issues." Indian Journal of Dermatology, Venereology & Leprology 75(1): 32-35. BACKGROUND AND AIMS: Teledermatology is an area that has shown rapid growth in the recent past. However, not many studies have been conducted with regards to the application of teledermatology in India. Aim of our study was to

evaluate the clinical profiles of cases referred for teledermatology consultation at our center, and to assess and compare the different modalities of teledermatology consultations done at our center along with the practical issues related to such a service. METHODS: A retrospective study of teledermatology consultations at our center over a 3-year period was carried out. Store-andforward (SAF), realtime consults (RTC), and hybrid (combining the two) were included.Two trained dermatologists were involved in carrying out the consultations in the referral center. RESULTS: Of the 120 consultations, 68 male and 52 female patients in the age range of 2-77 years were seen. In more than 90% of the cases, teleconsultation was the first contact for the patient with the dermatologist (for the present condition). In 68% of the cases, the reference was for both diagnosis and management, while in the rest, the reference was mainly related to management issues (appropriate diagnosis having already been made). Certainity of diagnosis was maximum for hybrid, SAF, and RTC. CONCLUSIONS: Teledermatology can prove valuable as a tool to provide healthcare in areas of shortage of specialists. A hybrid system combining SAF and RTC could be the ideal form of teledermatology consultations in the future. Many practical issues need to be addressed before the effectiveness of teledermatology in India can be fully recognized. Khalil, I. and F. Sufi (2009). "Cooperative remote video consultation on demand for epatients." Journal of Medical Systems 33(6): 475-483. With the advent of high-speed internet band-width consuming video conferencing applications will rapidly become attractive to e-patients seeking real-time video consultations from e-doctors. In a conventional system patients connect to a known server in a medical center of his choice. If the server (i.e. a server via which a medical consultant communicates with a patient) is busy, the patient must wait before the server becomes free. Such a system is not efficient as many patients in medical centers with busy servers may either have to wait long, or are simply turned away. Patients may also leave when they become impatient. Not only the patients suffer due to server unavailability, medical service providers also incur revenue losses due to lost patients. To counter these problems, we propose a distributed cooperative Video Consultation on Demand (VCoD) system where servers are located in many different medical centers in different neighbourhoods close to patient concentrations. In such a cooperative system if patients find their nearby servers under heavy load they are automatically directed to servers that are least loaded by using efficient server selection method (also called anycasting). Simple numerical analysis shows that this not only maximizes revenues for medical service providers by reducing number of lost patients, but also improves average response time for e-patients. Kim, D.-K., S. K. Yoo, et al. (2009). "A mobile telemedicine system for remote consultation in cases of acute stroke." Journal of Telemedicine & Telecare 15(2): 102107. A mobile telemedicine system, capable of transmitting video and audio simultaneously, was designed for consulting acute stroke patients remotely. It

could use a wireless local area network (e.g. inside the hospital) or a mobile phone network (e.g. outside the hospital). When initiating a call, the sending unit chose a suitable encoding profile based on the measured data throughput, in order to allocate appropriate bit rates for video and audio transmission. The system was tested using a portable digital assistant (PDA) type phone and smart phone as receiving units. Video and audio recordings were made from five patients (two normal and three stroke patients) and then transmitted at different rates. Subjectively, both video and audio qualities improved as the data throughput increased. The physical findings, including facial droop, arm drift and abnormal speech, were observed remotely by four specialists according to the Cincinnati Pre-hospital Stroke Scale guideline. A comparison between the faceto-face method and the mobile telemedicine method showed that there were no discrepancies at bit rates of more than 400 kbit/s. We conclude that specialists could generally conduct remote consultations for stroke patients either using a public mobile network or a wireless LAN. Kim, S.-I. and H.-S. Kim (2008). "Effectiveness of mobile and internet intervention in patients with obese type 2 diabetes." International Journal of Medical Informatics 77(6): 399-404. PURPOSE: The present study evaluated whether an intervention using the SMS by personal cellular phone and internet would improve the levels of plasma glucose of obese type 2 diabetes at 3, 6, 9, and 12 months. METHODS: This is a quasi-experimental design with pre- and follow-up tests. Participants were recruited from the endocrinology outpatient department of tertiary care hospital located in an urban city of South Korea. Eighteen patients were randomly assigned to an intervention group and 16 to a control group. The goal of the intervention was to decrease body weight and keep blood glucose concentrations close to the normal range. Patients were requested to record their blood glucose level in a weekly diary on the website by personal cellular phones or computer internet. The researcher sent optimal recommendations to each patient, by both the cellular phone and the Internet weekly. The intervention was applied for 1 year. RESULTS: Glycosylated hemoglobin (HbA(1)c) decreased 1.22 percentage points at 3 months, 1.09 percentage points at 6 months, 1.47 percentage points at 9 months, and 1.49 percentage points at 12 months compared with baseline in the intervention group (all time points, p<0.05). The percentage change in the control group was, however, not significant. Patients in the intervention group had a decrease of 2-h post-prandial test (2HPPT) of 120.1mg/dl at 3 months, 58.9 mg/dl at 6 months, 62.0mg/dl at 9 months, and 102.9 mg/dl at 12 months compared with baseline (all time points, p<0.05). The mean change in the control group was, however, not significant. CONCLUSION: This web-based intervention using SMS of personal cellular phone and Internet improved HbA(1)c and 2HPPT at 3, 6, 9, and 12 months in patients with obese type 2 diabetes. King, A. B. and G. S. Wolfe (2009). "Evaluation of a diabetes specialist-guided primary care diabetes treatment program." Journal of the American Academy of Nurse Practitioners 21(1): 24-30.

PURPOSE: An initial pilot program demonstrated promising results in improvements in glycosylated hemoglobin (HbA(1c)), low-density lipoprotein cholesterol (LDL-C), and systolic blood pressure (SBP) and prompted us to test these findings in a controlled trial. The purpose of the Diabetes-focused, Algorithm-directed care, Midlevel practitioner-administered, Electronically coached, Treatment (DAMET-2) program clinical trial was to investigate the benefits of a novel program for disseminating guidance in the treatment of diabetes from a central specialist clinic to primary care centers with access to midlevel provider services. DATA SOURCES: DAMET-2 included standardized treatment algorithms and education disseminated through computer-assisted and traditional methods associated with distance medicine. Two primary care practices were selected and subjects with diagnosed type 2 diabetes > or =6 months, > or =18 years of age with one or more cardiovascular risk factors (identified by chart review) were eligible for inclusion. Midlevel practitioners for subjects in the experimental group (N = 34) received training in American Diabetes Association treatment algorithms, had telephone consultations at 2- to 4-week intervals and bimonthly visits with diabetes specialists, and received treatment guidance within 24 h from remote diabetes specialists. Weekly diabetes clinics were made available to subjects in the experimental group. After 12 months, the last available subject data were extracted from the subjects' charts and compared to 12-month chart data from a control group (N = 101) that did not receive additional study services. CONCLUSIONS: Mean HbA(1c) values decreased from baseline by 0.46% in the active treatment group versus 0.06% in the control group; however, reductions in HbA(1c) did not achieve statistical significance potentially because of the small sample size of the experimental group. Mean SBP values were significantly reduced in both groups; however, LDL-C was only significantly reduced in the control group, where more aggressive use of statins may have had an effect. IMPLICATIONS FOR PRACTICE: Despite the inconsistencies in risk factor reduction from the pilot program, the DAMET-2 program provided insights regarding the importance of electronic records and provider notifications, patient adherence, prioritization of provider resources by risk factor level among patients, and access to selfmanagement education. Koay, N., P. Kataria, et al. (2010). "Semantic management of nonfunctional requirements in an e-health system." Telemedicine Journal & E-Health 16(4): 461-471. We have designed an ontological environment that makes provisions for choosing adequate devices for remote monitoring of patients who are suffering from poststroke health complications. We argue that nonfunctional requirements in e-health systems, designed for remote patient monitoring, can be managed through semantics stored in ontological models and reasoning performed on them. Our contribution is twofold: (1) we address the pervasiveness of e-health systems by choosing devices embedded in them, and through patients' expectations in terms of having access to pervasive health services personalized to their needs; and (2) we enrich the specification of nonfunctional requirements for remote patient monitoring by highlighting their role in the development of e-

healthcare systems. Koczwara, B., K. Francis, et al. (2010). "Reaching further with online education? The development of an effective online program in palliative oncology." Journal of Cancer Education 25(3): 317-323. Patients in rural and remote Australia have less access to specialist oncology services and rely more on local health professionals for provision of cancer care. We have developed a 7.5-h online educational program on palliative oncology for health professionals focused on the needs of rural providers. There were 501 active (enrolled) users and 268 ad hoc (non-enrolled) users, with 90 completing evaluation. Eighty-two (91%) indicated that their learning needs were partially or entirely met. Sixty-five (75%) respondents planned to review or change their practice as a result. The online program is effective in meeting learning needs of Australian health providers, reaching high numbers with high acceptability. Kraetschmer, N. M., R. B. Deber, et al. (2009). "Telehealth as gatekeeper: policy implications for geography and scope of services." Telemedicine Journal & E-Health 15(7): 655-663. Why, despite enthusiasm, is telehealth still a relatively minor part of healthcare delivery in many health systems? We examined two less-considered policy issues: (1) the scope of services being offered by telehealth and how this matches existing arrangements for insured services; and (2) how the ability of telehealth services to minimize barriers associated with geography is dealt with in a system organized and financed on geographical boundaries. Fifty-three semistructured interviews with key stakeholders involved in the management of 43 Canadian telehealth programs were conducted. In addition, quantitative activity data were analyzed from 33 telehealth programs. Two telehealth approaches emerged: telephone-based (N = 3), and video-conferencing-based (N = 40). Most programs reflected, rather than superceded, existing geographical boundaries; with the technology being used, the videoconferencing models imposed significant barriers to unfettered access by outlying communities because they required sites to acquire expensive technology, be affiliated with an existing telehealth network, and schedule visits in advance. In consequence, much activity was administrative and educational, rather than clinical, and often extended beyond the set of mandatory insured services. Despite high hopes that telehealth would improve access to care for rural/remote areas, gatekeeping inherent in certain telehealth systems imposes barriers to unfettered use by rural/remote areas, although it does facilitate other valued activities. Policy approaches are needed to promote a closer match between the expectations for telehealth and the realities reflected by many existing models. Krishna, S., K. N. Gillespie, et al. (2010). "Diabetes burden and access to preventive care in the rural United States." Journal of Rural Health 26(1): 3-11. CONTEXT: National databases can be used to investigate diabetes prevalence and health care use. Guideline-based care can reduce diabetes complications and morbidity. Yet little is known about the prevalence of diabetes and

compliance with diabetes care guidelines among rural residents and whether different national databases provide similar results. PURPOSE: To examine rural-urban differences in the prevalence of diabetes and compliance with guidelines, and to compare the Behavioral Risk Factor Surveillance System (BRFSS) and the Medical Expenditures Panel Survey (MEPS). METHODS: Data for 2001-2002 were analyzed and compared by rural-urban status. Prevalence was calculated as simple unadjusted, weighted unadjusted, and weighted adjusted using a multivariate approach. Results from the 2 databases were compared. FINDINGS: A slightly higher prevalence of diabetes among rural residents, 7.9% versus 6.0% in MEPS and 7.6% versus 6.6% in BRFSS, was found and persisted after adjustment for age, BMI, insurance coverage, and other demographic characteristics (adjusted OR 1.16 [1.02-1.31] in MEPS; 1.19 [1.01-1.20] in BRFSS). Rural persons in MEPS were less likely to receive an annual eye examination (aOR = 0.85) and a feet check (aOR = 0.89). A significantly (P < .05) smaller proportion of rural residents in BRFSS received an annual eye examination (aOR = 0.88), feet check (aOR = 0.85), or diabetes education (aOR = 0.83). Rural residents in both datasets were more likely to get a quarterly HbA1c test done. CONCLUSION: Rural residents in both datasets had higher prevalence of diabetes. Though not always statistically significant, the trend was to less guideline compliance in rural areas. Krsek, P., M. Spanel, et al. (2008). "Consultation virtual collaborative environment for 3D medicine." Conference Proceedings: ... Annual International Conference of the IEEE Engineering in Medicine & Biology Society 2008: 775-778. This article focuses on the problems of consultation virtual collaborative environment, which is designed to support 3D medical applications. This system allows loading CT/MR data from PACS system, segmentation and 3D models of tissues. It allows distant 3D consultations of the data between technicians and surgeons. System is designed as three-layer client-server architecture. Communication between clients and server is done via HTTP/HTTPS protocol. Results and tests have confirmed, that today's standard network latency and dataflow do not affect the usability of our system. Kurillo, G., R. Bajcsy, et al. (2009). "Teleimmersive environment for remote medical collaboration." Studies in Health Technology & Informatics 142: 148-150. We present the work in progress on teleimmersive framework that would allow doctors to collaborate in more natural way by being immersed in the virtual space along with the medical data they could examine and discuss with remotely located colleagues. The system consists of multiple cameras, hand tracking with gesture recognition, and virtual reality system to support volume visualization and 3D interaction with medical data. Kurillo, G., T. Koritnik, et al. (2011). "Real-time 3D avatars for tele-rehabilitation in virtual reality." Studies in Health Technology & Informatics 163: 290-296. We present work in progress on a tele-immersion system for telerehabilitation using real-time stereo vision and virtual environments. Stereo reconstruction is

used to capture user's 3D avatar in real time and project it into a shared virtual environment, enabling a patient and therapist to interact remotely. Captured data can also be used to analyze the movement and provide feedback to the patient as we present in a preliminary study of stepping-in-place task. Such telepresence system could in the future allow patients to interact remotely with remote physical therapist and virtual environment while objectively tracking their performance. Lai, F. (2009). "Stroke networks based on robotic telepresence." Journal of Telemedicine & Telecare 15(3): 135-136. In the USA, several telestroke networks have been successfully implemented in which a stroke centre of excellence provides expertise to community and rural hospitals via telemedicine. Stroke patients can thus receive round-the-clock access to stroke expertise. The Remote Presence (RP) system is used in several of these telestroke networks. The stroke expert uses a laptop and wireless Internet to connect to the RP robot in the peripheral emergency department. This improves the geographical reach of stroke specialist care, and improves patient outcomes as well as conforming with best practice. The stroke network concept combined with telemedicine is a powerful way of transforming stroke care. Le Goff-Pronost, M. and C. Sicotte (2010). "The added value of thorough economic evaluation of telemedicine networks." European Journal of Health Economics 11(1): 4555. This paper proposes a thorough framework for the economic evaluation of telemedicine networks. A standard cost analysis methodology was used as the initial base, similar to the evaluation method currently being applied to telemedicine, and to which we suggest adding subsequent stages that enhance the scope and sophistication of the analytical methodology. We completed the methodology with a longitudinal and stakeholder analysis, followed by the calculation of a break-even threshold, a calculation of the economic outcome based on net present value (NPV), an estimate of the social gain through external effects, and an assessment of the probability of social benefits. In order to illustrate the advantages, constraints and limitations of the proposed framework, we tested it in a paediatric cardiology tele-expertise network. The results demonstrate that the project threshold was not reached after the 4 years of the study. Also, the calculation of the project's NPV remained negative. However, the additional analytical steps of the proposed framework allowed us to highlight alternatives that can make this service economically viable. These included: use over an extended period of time, extending the network to other telemedicine specialties, or including it in the services offered by other community hospitals. In sum, the results presented here demonstrate the usefulness of an economic evaluation framework as a way of offering decision makers the tools they need to make comprehensive evaluations of telemedicine networks. LeRouge, C., B. Tulu, et al. (2010). "The business of telemedicine: strategy primer."

Telemedicine Journal & E-Health 16(8): 898-909. There is some tacit understanding that telemedicine can provide cost efficiency along with increased access and equality of care for the geographically disadvantaged. However, concrete strategic guidance for healthcare organizations to attain these benefits is fragmented and limited in existing literature. Telemedicine programs need to move from a grant-funded to a profitcentered status to sustain their existence. This article extends work presented at a recent American Telemedicine Association Business and Finance Special Interest Group course to provide a conceptual framework for strategic planning and for effectively implementing telemedicine programs. An expert panel of telemedicine coordinators provides insight and recommendations. Leveille, S. G., A. Huang, et al. (2009). "Health coaching via an internet portal for primary care patients with chronic conditions: a randomized controlled trial." Medical Care 47(1): 41-47. BACKGROUND: Efforts to enhance patient-physician communication may improve management of underdiagnosed chronic conditions. Patient internet portals offer an efficient venue for coaching patients to discuss chronic conditions with their primary care physicians (PCP). OBJECTIVES: We sought to test the effectiveness of an internet portal-based coaching intervention to promote patient-PCP discussion about chronic conditions. RESEARCH DESIGN: We conducted a randomized trial of a nurse coach intervention conducted entirely through a patient internet-portal. SUBJECTS: Two hundred forty-one patients who were registered portal users with scheduled PCP appointments were screened through the portal for 3 target conditions, depression, chronic pain, mobility difficulty, and randomized to intervention and control groups. MEASURES: One-week and 3-month patient surveys assessed visit experiences, target conditions, and quality of life; chart abstractions assessed diagnosis and management during PCP visit. RESULTS: Similar high percentages of intervention (85%) and control (80%) participants reported discussing their screened condition during their PCP visit. More intervention than control patients reported their PCP gave them specific advice about their health (94% vs. 84%; P = 0.03) and referred them to a specialist (51% vs. 28%; P = 0.002). Intervention participants reported somewhat higher satisfaction than controls (P = 0.07). Results showed no differences in detection or management of screened conditions, symptom ratings, and quality of life between groups. CONCLUSIONS: Internet portal-based coaching produced some possible benefits in care for chronic conditions but without significantly changing patient outcomes. Limited sample sizes may have contributed to insignificant findings. Further research should explore ways internet portals may improve patient outcomes in primary care. ClinicalTrials.gov registration NCT00130416. Liang, W.-Y., C.-Y. Hsu, et al. (2008). "Low-cost telepathology system for intraoperative frozen-section consultation: our experience and review of the literature." Human Pathology 39(1): 56-62. We have established a low-cost noncommercial system of dynamic real-time

telepathology for light microscopic diagnosis that was used to aid intradepartmental consultation for frozen-section diagnosis. Fifty cases were performed. For each case, multiple diagnoses were made and compared, namely, those made by the pathologist on duty (D1), by a subspecialist or senior using telepathology (D2), by the same pathologist using a light microscope (D3), and the final diagnosis (D4). A comparison of D1 and D2 revealed that 37 cases (74%) were diagnosed more precisely by D2. In 9 (18%) of 50 cases, there was a positive major impact on the operation as a result of teleconsultation. The results of D2 and D3 showed good agreement (kappa = 0.97). The average time span required for telepathology is short compared with routine intradepartmental consultation. Our experience showed that telepathology is a good tool for frozensection consultation and imposes little additional cost. [References: 21] Lienert, N., N. U. Zitzmann, et al. (2010). "Teledental consultations related to trauma in a Swiss telemedical center: a retrospective survey." Dental Traumatology 26(3): 223227. BACKGROUND/AIM: In addition to medical advice, telemedical centers also provide counseling on the telephone for patients with dental injuries. MATERIAL AND METHODS: Data from a Swiss telemedical center during the years 20012008 were analyzed retrospectively. RESULTS: A total of 371 988 medical consultations were recorded. Of these, 3430 concerned dental problems, with 672 reports about dental trauma following accidents with 772 injuries. The patients average age was 8.6 years (range 0-73 years). About two-thirds of the cases belonged to the age group 0-6 years, and one-third to the group of 7-80 years. The reasons for calling were dislocations (53%), fractures (31.9%), and avulsions (7.9%). In 76.2% of the cases, the center was contacted on the day of the accident. The majority of the patients (60%) contacted the telemedical center during the so-called 'out of office hours' (Monday to Friday 6 pm to 8 am, and Saturday/Sunday all day). CONCLUSIONS: Telemedicial services can be helpful for cases related to dental trauma and may provide valuable support when a dentist is not available. Lim, T. H., H. J. Choi, et al. (2010). "Feasibility of dynamic cardiac ultrasound transmission via mobile phone for basic emergency teleconsultation." Journal of Telemedicine & Telecare 16(5): 281-285. We assessed the feasibility of using a camcorder mobile phone for teleconsulting about cardiac echocardiography. The diagnostic performance of evaluating left ventricle (LV) systolic function was measured by three emergency medicine physicians. A total of 138 short echocardiography video sequences (from 70 subjects) was selected from previous emergency room ultrasound examinations. The measurement of LV ejection fraction based on the transmitted video displayed on a mobile phone was compared with the original video displayed on the LCD monitor of the ultrasound machine. The image quality was evaluated using the double stimulation impairment scale (DSIS). All observers showed high sensitivity. There was an improvement in specificity with the observer's increasing experience of cardiac ultrasound. Although the image quality of video

on the mobile phone was lower than that of the original, a receiver operating characteristic (ROC) analysis indicated that there was no significant difference in diagnostic performance. Immediate basic teleconsulting of echocardiography movies is possible using current commercially-available mobile phone systems. Lingley-Pottie, P. and P. J. McGrath (2008). "A paediatric therapeutic alliance occurs with distance intervention." Journal of Telemedicine & Telecare 14(5): 236-240. We investigated whether a distance therapeutic alliance occurs when children receive manualized, cognitive-behavioural treatment via telephone, in the absence of face-to-face contact. The therapeutic alliance scores were measured in 55 child-parent pairs. The mean total Working Alliance Inventory child scores were 236 (95% confidence interval [CI]: 232, 240) and the mean parent scores were 245 (95% CI: 242, 247). Parent scores were significantly higher than child scores, although the difference may not be clinically meaningful. This study provides evidence that a strong therapeutic alliance does occur between childcoach and parent-coach pairs when treatment is delivered from a distance by non-professionals. The term 'child' encompasses both children and adolescents. Llibre, J. M., P. Domingo, et al. (2008). "Long-distance interactive expert advice in highly treatment-experienced HIV-infected patients." Journal of Antimicrobial Chemotherapy 61(1): 206-209. OBJECTIVES: To determine the feasibility and outcomes of long-distance interactive expert advice for treatment-experienced patients. METHODS: HIV-1infected patients on failing highly active antiretroviral therapy (HAART) were prospectively submitted for consultation by treating physicians to an expert panel using a standard e-mail form including: resistance tests, antiretroviral history, adherence, CD4 counts, HIV-1-RNA levels and HCV/HBV co-infection. Conference calls (CCs) were scheduled monthly to discuss 10 new patients. RESULTS: One hundred and fifteen patients were discussed (86% male; 45% intravenous drug users). The median length of HIV infection was 10 years and subjects were treated for a median of 8 years with a median of 5.25 previous HAART regimens. Ninety per cent were triple-class experienced [nucleoside reverse transcriptase inhibitors (NRTIs)/non-NRTIs (NNRTIs)/protease inhibitors (PIs)]. Median CD4 cell count was 298 cells/mm(3) and median viral load was 19 700 copies/mL. Overall, 60% had >or=5 reverse transcriptase mutations and 67% had >or=5 protease mutations, and most patients were NNRTI-resistant. Drugs more frequently recommended by experts were: lamivudine/emtricitabine > tenofovir > abacavir > zidovudine > didanosine > stavudine (NRTIs) and tipranavir > lopinavir > atazanavir > saquinavir (PIs). Enfuvirtide was recommended in 65% of cases. Concordance between recommended and prescribed regimens was 74.7%. Virtually all discordances were due to patient refusal of complex regimens. Outcomes at 24 weeks: HIV-1-RNA <50 copies/mL in 42% of patients, HIV-1-RNA <400 copies/mL in 59.4% of patients and median CD4 increase was 77 (14-140) cells/mm(3). CONCLUSIONS: Long-distance interactive expert advice is feasible for complex treatment-experienced HIV patients using e-mail and CCs. Adherence to treatment recommendations is

high, with encouraging viro-immunological outcomes at 24 weeks. This strategy merits further investigation, especially in clinical settings where availability of local experts is limited. Locatis, C., D. Williamson, et al. (2010). "Comparing in-person, video, and telephonic medical interpretation." Journal of General Internal Medicine 25(4): 345-350. BACKGROUND: Using trained interpreters to provide medical interpretation services is superior to services provided on an ad hoc basis, but little is known about the effectiveness of providing their services remotely, especially using video. OBJECTIVE: To compare remote medical interpretation services by trained interpreters via telephone and videoconference to those provided inperson. DESIGN: Quasi-randomized control study. PARTICIPANTS: Two hundred and forty-one Spanish speaking patient volunteers, twenty-four health providers, and seven interpreters. APPROACH: Patients, providers and interpreters each independently completed scales evaluating the quality of clinical encounters and, optionally, made free text comments. Interviews were conducted with 23 of the providers, the seven interpreters, and a subset of 30 patients. Time data were collected. RESULTS: Encounters with in-person interpretation were rated significantly higher by providers and interpreters, while patients rated all methods the same. There were no significant differences in provider and interpreter ratings of remote methods. Provider and interpreter comments on scales and interview data support the higher in-person ratings, but they also showed a distinct preference for video over the phone. Phone interviews were significantly shorter than in-person. DISCUSSION: Patients rated interpretation services highly no matter how they were provided but experienced only the method employed at the time of the encounter. Providers and interpreters were exposed to all three methods, were more critical of remote methods, and preferred videoconferencing to the telephone as a remote method. The significantly shorter phone interviews raise questions about the prospects of miscommunication in telephonic interpretation, given the absence of a visual channel, but other factors might have affected time results. Since the patient population studied was Hispanic and predominantly female care must be taken in generalizing these results to other populations. Logeswaran, R. (2009). "Customizable wireless remote control for collaborative medical diagnosis and teaching." Journal of Medical Systems 33(5): 389-398. Effective collaborative diagnosis, in a presentation environment, requires the presenter's ability to control equipment at a distance. Conventional remote control multimedia presenters suffice for basic functionality of presentation applications. However, such factory-made remote controls are not particularly useful for a wider variety of applications, especially in the medical field where effective use of the systems and applications require the use of different keys. This paper reports the development of a USB (universal serial bus) remote control with customizable buttons, using RF (radio frequency) technology and allowing for effective control for a large range of manipulations on a workstation. Description of the implementation ideas and results achieved in the development

of the firmware and hardware for such a technological tool for use in improving collaborative medical diagnosis and teaching are presented in this article. Loh, P.-K., L. Flicker, et al. (2009). "Attitudes toward information and communication technology (ICT) in residential aged care in Western Australia." Journal of the American Medical Directors Association 10(6): 408-413. OBJECTIVES: Determine why introduction of health consulting services via Telehealth video conference consultations failed in residential aged care facilities (RACF). DESIGN: Semistructured interview groups and quantitative survey. SETTING: Two participating not-for-profit RACF. PARTICIPANTS: Managers, employed carers, physiotherapist, occupational therapist, registered nurses, and residents from RACF. MEASUREMENTS: A survey initially followed by focus groups that centered on 4 questions. How can computers help improve care? What kind of electronic services and products could help improve care? Who should have access to the technology and why was the technology not used? RESULTS: The survey revealed there was awareness of information and communication technology (ICT) in RACF. However, respondents were uncertain of potential benefits provided to their clients. Only 43% of respondents thought a minority of clients would receive the benefits of ICT use. The focus groups revealed several themes regarding the attitudes toward ICT in RACF. Positive attitudes to ICT included themes of saving time, easier doctor access, cost saving, and improved communications. Negative attitudes included themes of loss of human contact, inadequate training, security barriers, not user friendly, limited ability to comply with suggestions, privacy issues, and capital cost. Residents were also concerned about confidentiality and loss of human interaction with the use of Telehealth in residential aged facilities. CONCLUSIONS: More training for staff is required to enable them to use ICT efficiently. ICT hardware and software at the user interface must be designed to maintain confidentiality with ease of access. Access to Telehealth services should not impede the routine delivery of personal care and human contact for residents. Studies are required as to where human input to residents is unable to be replaced by Telehealth services. Lotz, G., T. Peters, et al. (2010). "A domain model of a clinical reading center - Design and implementation." Conference Proceedings: ... Annual International Conference of the IEEE Engineering in Medicine & Biology Society 2010: 4530-4533. In clinical trials huge amounts of raw data are generated. Often these data are submitted to reading centers for being analyzed by experts of that particular type of examination. Although the installment of a reading center can raise the overall quality, they also introduce additional complexity to the management and conduction of a clinical trial. Software can help to handle this complexity. Domain-driven-design is one concept to tackle software development in such complex domains. Here we present our domain model for a clinical reading center, as well as its actual implementation utilizing the Nuxeo enterprise content management system.

Ludwick, D. A., C. Lortie, et al. (2010). "Evaluation of a telehealth clinic as a means to facilitate dermatologic consultation: pilot project to assess the efficiency and experience of teledermatology used in a primary care network." Journal of Cutaneous Medicine & Surgery 14(1): 7-12. BACKGROUND: Primary care offices spend considerable time coordinating the specialist referral process. Patients experience long wait times for consultation and intervention. OBJECTIVE: To determine if telehealth combined with interdisciplinary team-based care can reduce wait times for dermatologic consultation while making the consultation process easier for physicians. METHODS: Retrospective chart reviews as well as patient, referring physician, nonreferring physician, clinic physician, nurse, and teledermatologist interviews were used to evaluate the clinic. A comparative immersion approach generated themes from field notes. Wait times, appointment times, and encounter durations were measured. RESULTS: Twenty-eight patients were seen (23 had previous specialist referral experience) within 1 week of referral compared to a wait period of 104 days for conventional referral. Patients requiring intervention were treated within 1 week of their initial appointment. Referring practitioners were concerned that they would lose control of patients' care. An easier referral process and faster intakes met physician expectations. CONCLUSIONS: Teledermatology improves the timeliness of appointments. Patients forgo face-to-face appointments if alternatives are available sooner. Physicians are concerned about their own liability if dermatologists do not assess the patient in person but will refer through teledermatology when patients are seen faster and they remain in control of the care process. Maffei, R., Y. Hudson, et al. (2008). "Telemedicine for urban uninsured: a pilot framework for specialty care planning for sustainability." Telemedicine Journal & EHealth 14(9): 925-931. A national approach to medical care for the uninsured is for the provision of primary and preventive care through Community Health Centers. Access to specialty care for both Medicaid and uninsured patients is in decline even though specialty care has been shown to be cost-effective and improve outcomes. The consequences could result in further deterioration of the health of the uninsured and underinsured populations and increasing costs born by the insured and safety net providers. Telemedicine can provide specialty services efficiently if planned with a business model to sustain the program. This paper outlines a pilot framework to plan and cost-justify telemedicine specialty care for the uninsured and marginally insured. This potential framework is supported by data from an urban community with the highest concentration of uninsured in the country: Houston, Texas. Further study and evaluation will be needed once the framework and tools are implemented to empirically prove the sustainability of telemedicine specialty care for the urban uninsured. Marzegalli, M., M. Landolina, et al. (2009). "Design of the evolution of management strategies of heart failure patients with implantable defibrillators (EVOLVO) study to assess the ability of remote monitoring to treat and triage patients more effectively."

Trials [Electronic Resource] 10: 42. BACKGROUND: Heart failure patients with implantable defibrillators (ICD) frequently visit the clinic for routine device monitoring. Moreover, in the case of clinical events, such as ICD shocks or alert notifications for changes in cardiac status or safety issues, they often visit the emergency department or the clinic for an unscheduled visit. These planned and unplanned visits place a great burden on healthcare providers. Internet-based remote device interrogation systems, which give physicians remote access to patients' data, are being proposed in order to reduce routine and interim visits and to detect and notify alert conditions earlier. METHODS: The EVOLVO study is a prospective, randomized, parallel, unblinded, multicenter clinical trial designed to compare remote ICD management with the current standard of care, in order to assess its ability to treat and triage patients more effectively. Two-hundred patients implanted with wireless-transmission-enabled ICD will be enrolled and randomized to receive either the Medtronic CareLink monitor for remote transmission or the conventional method of in-person evaluations. The purpose of this manuscript is to describe the design of the trial. The results, which are to be presented separately, will characterize healthcare utilizations as a result of ICD follow-up by means of remote monitoring instead of conventional in-person evaluations. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00873899. Massone, C., A. M. G. Brunasso, et al. (2010). "Teledermoscopy: education, discussion forums, teleconsulting and mobile teledermoscopy." Giornale Italiano di Dermatologia e Venereologia 145(1): 127-132. Teledermoscopy has become in the last years one of the most florid reality of teledermatology. Parallel to the achievement of dermoscopy in clinical settings, teledermoscopy has grown in different fields, namely tele-education and teleconsulting. Blogs, atlases, discussion forums, on line courses and Diploma Courses do not only offer a second opinion consultation but give the opportunity to residents in dermatology and dermatologists with different level of expertise in dermoscopy to easily learn at home, to train or to improve their level in dermoscopy. On the other side, in some countries demand for melanoma screening has led to commercialization of "teledermoscopy" by different companies. Images nowadays can be transmitted over telecommunication networks not only via e-mail or a specific web application but also with last generation cellular phones. This reality opens the new incoming field of mobile teledermatology. Mobile teledermoscopy is a new horizon that might become in the future the basis of the self examination of pigmented skin lesions as a screening tool for malignant cutaneous tumors or to follow-up of high risk patients. May, C., R. Harrison, et al. (2003). "Why do telemedicine systems fail to normalize as stable models of service delivery?" Journal of Telemedicine & Telecare 9 Suppl 1: S2526. Two groups independently carried out qualitative studies of the development, implementation and evaluation of telehealth systems and services in the UK. The

data collected (in more than 600 discrete data collection episodes) included semistructured interviews, observations and documents. We conducted a conjoint reanalysis of the data. The objective was to identify the conditions which dispose a telehealth service to be successful or to fail. There appear to be four conditions necessary for a telemedicine system to stabilize and then normalize as a means of service delivery. When one or more is absent, failure can be expected. These conditions are often overlooked by local proponents of telemedicine, who seem to rely on demonstrations that the equipment works as the primary criterion of success. McCarthy, M., K. Munoz, et al. (2010). "Teleintervention for infants and young children who are deaf or hard-of-hearing." Pediatrics 126 Suppl 1: S52-58. Advancements in videoconferencing equipment and Internet-based tools for sharing information have resulted in widespread use of telemedicine for providing health care to people who live in remote areas. Given the limited supply of people trained to provide early-intervention services to infants and young children who are deaf or hard-of-hearing, and the fact that many families who need such services live significant distances from each other and from metropolitan areas, such "teleintervention" strategies hold promise for providing early-intervention services to children who are deaf or hard-of-hearing. Unfortunately, little is known about the cost-effectiveness of such teleintervention services. In this article we outline the rationale for using teleintervention services for children who are deaf or hard-of-hearing, describe a teleintervention program that has been serving relatively large numbers of children in Australia since 2002, and summarize what we know about the cost-effectiveness of such an approach. We conclude by summarizing the type of research needed to decide whether teleintervention should be used more frequently with children who are deaf or hard-of-hearing and the potential relevance of the teleintervention approach for the development of intervention systems in the United States. McConnochie, K., N. Wood, et al. (2010). "Integrating telemedicine in urban pediatric primary care: provider perspectives and performance." Telemedicine Journal & E-Health 16(3): 280-288. BACKGROUND: Health-e-Access, an urban telemedicine service, enabled 6,511 acute-illness telemedicine visits over a 7-year period for children at 22 childcare and school sites in Rochester, NY. OBJECTIVES: The aims of this article were to (1) describe provider attitudes and perceptions about efficiency and effectiveness of Health-e-Access and (2) assess hypotheses that (a) providers will complete a large proportion of the telemedicine visits attempted and (b) high levels of continuity with the primary care practice will be achieved. DESIGN/METHODS: This descriptive study focused on the 24-month Primary Care Phase in the development of Health-e-Access, initiated by the participation of 10 primary care practices. Provider surveys addressed efficiency, effectiveness, and overall acceptability. Performance measures included completion of telemedicine visits and continuity of care with the medical home. RESULTS: Among survey respondents, the 30 providers who had completed telemedicine visits perceived

that decision-making required slightly less time and total time required was slightly greater than for in-person visits. Confidence in diagnosis was somewhat less for telemedicine visits. Providers were comfortable collaborating with telemedicine assistants and confident that communications met parent needs. Among the 2,554 consecutive telemedicine visits attempted during the Primary Care Phase, 2,475 (96.9%) were completed by 47 providers. For visits by children with a participating primary care practice, continuity averaged 83.2% among practices (range, 28.1-92.9%). CONCLUSIONS: Providers perceived little or no advantage in efficiency or effectiveness to their practice in using telemedicine to deliver care; yet they used it effectively in serving families, completing almost all telemedicine visits requested, providing high levels of continuity with the medical home, and believing they communicated adequately with parents. McConnochie, K. M., N. E. Wood, et al. (2009). "Acute illness care patterns change with use of telemedicine." Pediatrics 123(6): e989-995. OBJECTIVE: Health-e-Access, a telemedicine service providing care for acute illnesses in children, has delivered >6500 telemedicine visits from 10 primary care practices in Rochester, New York, by using telemedicine access at 22 child care and school sites. The goal was to assess the hypotheses that children served by Health-e-Access received health care more often for acute illnesses but had fewer emergency department (ED) visits and lower health care expenditures than did children without access through this service. METHODS: By using insurance claims, this case study compared utilization (starting in May 2001) of telemedicine, office, or ED care for children with versus without telemedicine access. Children included in analyses had > or =6 consecutive insurance-covered months through July 2007. Claims data captured all utilization. A total of 19 652 child-months from 1216 children with telemedicine access were matched with respect to age, gender, socioeconomic status, and season with child-months for children without telemedicine availability. RESULTS: The mean age at utilization was 6.71 years, with 79% of all childmonths being covered by Medicaid managed care. The overall utilization rate was 305.1 visits per 100 child-years. In multivariate analyses with adjustment for potential confounders, overall illness-related utilization rates (in-person or telemedicine visits per 100 child-years) for all sites were 23.5% greater for children with telemedicine access than for control children, but ED utilization was 22.2% less. CONCLUSION: The Health-e-Access telemedicine model holds potential to reduce health care costs, mostly through replacement of ED visits for nonemergency problems. McKinstry, B., P. Watson, et al. (2011). "Comparison of the accuracy of patients' recall of the content of telephone and face-to-face consultations: an exploratory study." Postgraduate Medical Journal 87(1028): 394-399. BACKGROUND To comply with an action plan patients need to recall information accurately. Little is known about how well patients recall consultations, particularly telephone consultations increasingly used to triage acute problems.

PURPOSE OF STUDY This was an exploratory study to measure how accurately patients recall the content of face-to-face and telephone consultations and what factors may be associated with accurate recall. STUDY DESIGN In Scotland in 2008, the advice (diagnoses; management plan(s); and safety-netting arrangements) given in audio recorded face-to-face and telephone consultations was compared with the advice recalled by patients at interview approximately 13&emsp14;days later. Patients also performed a memory test. Interactions were sought between accurate recall, consultation type, and factors postulated to influence recall. RESULTS Ten general practitioners (GPs) and 175 patients participated; 144 (82%) patients were interviewed. Patients recalled most important components of telephone and face-to-face consultations equally accurately or with only minor errors. Overall, patients presenting multiple problems (p<0.001), with brain injury (p<0.01) or low memory score (p<0.01) had reduced recall. GPs rarely used strategies to improve recall; however, these were not associated with improved recall. CONCLUSIONS Contrary to previous hospital based research, patients tended to remember important components of both face-to-face and telephone consultations-perhaps reflecting the familiar, less anxiety provoking environment of primary care. The unsuccessful use of strategies to improve recall may reflect selective use in cognitively impaired patients. Clinicians should compensate for situations where recall is poorer such as patients presenting multiple problems or with brain injury. Patients might be advised to restrict the number of problems they present in any one consultation. McKinstry, B., P. Watson, et al. (2009). "Telephone consulting in primary care: a triangulated qualitative study of patients and providers." British Journal of General Practice 59(563): e209-218. BACKGROUND: Internationally, there is increasing use of telephone consultations, particularly for triaging requests for acute care. However, little is known about how this mode of consulting differs from face-to-face encounters. AIM: To understand patient and healthcare-staff perspectives on how telephone consulting differs from face-to-face consulting in terms of content, quality, and safety, and how it can be most appropriately incorporated into routine health care. DESIGN OF STUDY: Focus groups triangulated by a national questionnaire. SETTING: Primary care in urban and rural Scotland. METHOD: Fifteen focus groups (n = 91) were conducted with GPs, nurses, administrative staff, and patients, purposively sampled to attain a maximum-variation sample. Findings were triangulated by a national questionnaire. RESULTS: Telephone consulting evolved in urban areas mainly to manage demand, while in rural areas it developed to overcome geographical problems and maintain continuity of care for patients. While telephone consulting was generally seen to provide improved access, clinicians expressed strong concerns about safety potentially being compromised, largely as a result of lack of formal and informal examination. Concerns were, to an extent, allayed when clinicians and patients knew each other well. CONCLUSION: Used appropriately, telephone consulting enhances access to health care, aids continuity, and saves time and travelling for patients. The current emphasis on use for acute triage, however, worried clinicians and

patients. Given these findings, and until the safe use of telephone triage is fully understood and agreed upon by stakeholders, policymakers and clinicians should consider using the telephone primarily for managing follow-up appointments when diagnostic assessment has already been undertaken. McLean, R., C. Jury, et al. (2009). "Application of camera phones in telehaematology." Journal of Telemedicine & Telecare 15(7): 339-343. We investigated the use of camera phones for telehaematology. First, the minimum requirements for the camera phones to be used in telehaematology were investigated. A single image containing white cells, red cells and platelets was sent from a camera phone to 33 different camera phones. Nine of the camera phones were found to be unsuitable for telehaematology due to low display resolution or no zoom function of the image. Then we examined the agreement between a haematologist using a suitable camera phone for remote diagnosis and the blood film report made in the usual way. Blood samples were collected from nine patients who had conditions in which diagnostically important morphological abnormalities occurred. In seven of the nine cases, the telehaematology responses were similar to the documented blood film reports. We conclude that telehaematology using camera phones offers a quick and potentially valuable method of support for the diagnostic haematology laboratory. McManus, J., J. Salinas, et al. (2008). "Teleconsultation program for deployed soldiers and healthcare professionals in remote and austere environments." Prehospital & Disaster Medicine 23(3): 210-216; discussion 217. BACKGROUND: In April 2004, the US Army Medical Department approved the use of the Army Knowledge Online (AKO) electronic e-mail system as a teleconsultation service for remote teledermatology consultations from healthcare providers in Iraq, Kuwait, and Afghanistan to medical subspecialists in the United States. The success of the system has resulted in expansion of the telemedicine program to include 11 additional clinical specialty services: (1) burn-trauma; (2) cardiology; (3) dermatology; (4) infectious disease; (5) nephrology; (6) ophthalmology; (7) pediatric intensive care; (8) preventive and occupational medicine; (9) neurology; (10) rheumatology; and (11) toxicology. The goal of the program is to provide a mechanism for enhanced diagnosis of remote cases resulting in a better evacuation system (i.e., only evacuation of appropriate cases). The service provides a standard practice for managing acute and emergent care requests between remote medical providers in austere environments and rear-based specialists in a timely and consistent manner. METHODS: Consults are generated using the AKO e-mail system routed through a contact group composed of volunteer, on-call consults. The project manager receives and monitors all teleconsultations to ensure Health Insurance Portability and Accountability Act compliance and consultant's recommendations are transmitted within a 24-hour mandated time period. A subspecialty "clinical champion" is responsible for recruiting consultants to answer teleconsultations and developing a call schedule for each specialty. Subspecialties may have individual consultants on call for specific days (e.g., dermatology and toxicology)

or place entire groups on-call for a designated period of time (e.g., ophthalmology). RESULTS: As of May 2007, 2,337 consults were performed during 36 months, with an average reply time of five hours from receipt of the teleconsultation until a recommendation was sent to the referring physician. Most consultations have been for dermatology (66%), followed by infectious disease (10%). A total of 51 known evacuations were prevented from use of the program, while 63 known evacuations have resulted following receipt of the consultants' recommendation. A total of 313 teleconsultations also have been performed for non-US patients, CONCLUSIONS: The teleconsultation program has proven to be a valuable resource for physicians deployed in austere and remote locations. Furthermore, use of such a system for physicians in austere environments may prevent unnecessary evacuations or result in appropriate evacuations for patients who initially may have been "underdiagnosed." Miley, M. L., B. M. Demaerschalk, et al. (2009). "The state of emergency stroke resources and care in rural Arizona: a platform for telemedicine." Telemedicine Journal & E-Health 15(7): 691-699. A rural-urban disparity exists in acute stroke management practices in Arizona. A proposed solution is a statewide acute stroke care plan centered on stroke telemedicine. Our purpose was to evaluate the emergency stroke resources available at and care provided by remote Arizona hospitals and to formulate a 5year stroke telemedicine plan for Arizona rural residents. We used the Arizona Hospital and Healthcare Association Web site to identify all eligible institutions. Consenting personnel were mailed the survey on behalf of the Arizona Department of Health Services. To construct the 5-year telemedicine plan, we used survey data as well as our previously designed stroke telemedicine research trial. We estimated the resources, the geographic coverage, and the operating costs. Thirty-five hospitals met survey eligibility criteria; however, 24/35 (69%) hospitals completed the survey. Only one hospital had neurologists on call 24/7. Hospitals thrombolysed 2%-4% of all stroke patients annually. Ninety percent of the hospitals were interested in participating in a statewide telemedicine initiative. The stroke telemedicine plan divided Arizona into two regions, each with a one-hub to three-spoke ratio. The budget was estimated to be U.S. $8,141,217.10 for 5 years. Remote communities of Arizona were underserviced with regard to the availability of neurologists and the delivery of emergency stroke care. The majority of the remote emergency departments were interested in participating as spoke sites in a statewide stroke telemedicine initiative. Telemedicine may be an effective method to provide expert care to stroke patients located in rural areas. Miller, E. A. (2011). "The continuing need to investigate the nature and content of teleconsultation communication using interaction analysis techniques." Journal of Telemedicine & Telecare 17(2): 55-64. The lack of systematically collected and analysed data about the effect of telemedicine on patient-provider communication is a frequently cited barrier for why video communication has yet to reach its full potential. Existing research

provides little information about the subtle and detailed changes in communication that take place over video. Comprehensive investigations of actual medical encounter behaviour are therefore required, including verbal content analysis, which uses interaction analysis systems (IAS) to describe and categorize the communication that has taken place. Ten IAS studies were identified in the literature. Although it is difficult to generalize due to differences in methodology and context, some tentative conclusions can be drawn. First, onsite providers tend to be substantially less active than off-site providers, suggesting that the former typically serve as facilitators and observers, rather than active participants. Second, just as in the conventional face-to-face setting, providers' utterances tend to predominate in telemedicine. Third, conventional patterns of more task-focused than socio-emotional utterances tend to persist in telemedicine. However, some studies found telemedicine to be more patientcentred than conventional medicine, and others found it less so. We do not yet have a full understanding of the subtractive and enhancing effects of telemedicine on provider-patient relations and outcomes. Mines, M. J., K. S. Bower, et al. (2011). "The United States Army Ocular Teleconsultation program 2004 through 2009." American Journal of Ophthalmology 152(1): 126-132.e122. PURPOSE: To describe the United States Army Ocular Teleconsultation program and all consultations received from its inception in July 2004 through December 2009. DESIGN: Retrospective, noncomparative, consecutive case series. METHODS: All 301 consecutive ocular teleconsultations received were reviewed. The main outcome measures were differential diagnosis, evacuation recommendations, and origination of consultation. Secondary measures included patient demographics, reason for consultation, and inclusion of clinical images. RESULTS: The average response time was 5 hours and 41 minutes. Most consultations originated from Iraq (58.8%) and Afghanistan (18.6%). Patient care-related requests accounted for 94.7% of consultations; nonphysicians submitted 26.3% of consultations. Most patients (220/285; 77.2%) were United States military personnel; the remainder included local nationals and coalition forces. Children accounted for 23 consultations (8.1%). Anterior segment disease represented the largest grouping of cases (129/285; 45.3%); oculoplastic problems represented nearly one quarter (68/285; 23.9%). Evacuation was recommended in 123 (43.2%) of 285 cases and in 21 (58.3%) of 36 cases associated with trauma. Photographs were included in 38.2%, and use was highest for pediatric and strabismus (83.3%) and oculoplastic (67.6%) consultations. Consultants facilitated evacuation in 87 (70.7%) of 123 consultations where evacuation was recommended and avoided unnecessary evacuations in 28 (17.3%) of 162 consultations. CONCLUSIONS: This teleconsultation program has brought valuable tertiary level support to deployed providers, thereby helping to facilitate appropriate and timely referrals, and in some cases avoiding unnecessary evacuation. Advances in remote diagnostic and imaging technology could further enhance consultant support to distant providers and their patients. Published by Elsevier Inc.

Mlyniec, P., J. Jerald, et al. (2011). "iMedic: a two-handed immersive medical environment for distributed interactive consultation." Studies in Health Technology & Informatics 163: 372-378. We describe a two-handed immersive and distributed 3D medical system that enables intuitive interaction with multimedia objects and space. The system is applicable to a number of virtual reality and tele-consulting scenarios. Various features were implemented, including measurement tools, interactive segmentation, non-orthogonal planar views, and 3D markup. User studies demonstrated the system's effectiveness in fundamental 3D tasks, showing that iMedic's two-handed interface enables placement and construction of 3D objects 4.5-4.7 times as fast as a mouse interface and 1.3-1.7 times as fast as a onehanded wand interface. In addition, avatar-to-avatar collaboration (two iMedic users in a shared space-one subject and one mentor) was shown to be more effective than face-to-face collaboration (one iMedic user/subject and one live mentor) for three tasks. Moffatt, J. J. and D. S. Eley (2011). "Barriers to the up-take of telemedicine in Australia-a view from providers." Rural & Remote Health 11: 1581. INTRODUCTION: The continued poorer health status of rural and remote Australians when compared with their urban counterparts is cause for concern. The use of advanced technology to improve access to health care has the potential to assist in addressing this problem. Telemedicine is one example of such technology which has advanced rapidly in its capacity to increase access to healthcare services or provide previously unavailable services. The important anticipated benefits of greater access to healthcare services are improved health outcomes and more cost-effective delivery. METHODS: A national study was conducted to investigate the current perceived use and usefulness of telemedicine from the perspective of users and providers, and their views on how telemedicine could be expanded in Australia. In one component of this national study, the expert opinion of experienced providers of telemedicine services was elicited using a Grounded Theory approach and using semi-structured interviews which were analysed thematically. This article reports on the barriers to the uptake of telemedicine identified by this sub-sample. RESULTS: The primary barriers identified were: funding; time; infrastructure; equipment; skills; and preference for the traditional approach. While funding is a well-known barrier to the up-take of telemedicine, the extra time required for a telemedicine consultation has particular implications for the workload of rural doctors. The comparatively poor internet access available in rural Australia combines with difficulties accessing some items such as a computer, to make equipment an issue. Even though lack of equipment skills was identified as a barrier, the providers in this study reported that rural doctors are adept at using the telephone/teleconferencing and facsimile. A preference for a traditional approach can reflect a lack of interest in learning computer skills or difficulty acquiring this skill set. CONCLUSIONS: These results raise issues in the domains of policy, funding priorities, and education and training. This indicates an inter-related set

of challenges that would require a targeted multifaceted approach to address. The results suggest that not using telemedicine is, in the current climate, a rational response--it is quicker, easier and more cost-effective not to use telemedicine. Mohr, D. C., J. Duffecy, et al. (2010). "Multimodal e-mental health treatment for depression: a feasibility trial." Journal of Medical Internet Research 12(5): e48. BACKGROUND: Internet interventions for depression have shown less than optimal adherence. This study describes the feasibility trial of a multimodal emental health intervention designed to enhance adherence and outcomes for depression. The intervention required frequent brief log-ins for self-monitoring and feedback as well as email and brief telephone support guided by a theorydriven manualized protocol. OBJECTIVE: The objective of this feasibility trial was to examine if our Internet intervention plus manualized telephone support program would result in increased adherence rates and improvement in depression outcomes. METHODS: This was a single arm feasibility trial of a 7week intervention. RESULTS: Of the 21 patients enrolled, 2 (9.5%) dropped out of treatment. Patients logged in 23.2 +/- 12.2 times over the 7 weeks. Significant reductions in depression were found on all measures, including the Patient Health Questionnaire depression scale (PHQ-8) (Cohen's d = 1.96, P < .001), the Hamilton Rating Scale for Depression (d = 1.34, P < .001), and diagnosis of major depressive episode (P < .001). CONCLUSIONS: The attrition rate was far lower than seen either in Internet studies or trials of face-to-face interventions, and depression outcomes were substantial. These findings support the feasibility of providing a multimodal e-mental health treatment to patients with depression. Although it is premature to make any firm conclusions based on these data, they do support the initiation of a randomized controlled trial examining the independent and joint effects of Internet and telephone administered treatments for depression. Moreno-Ramirez, D., L. Ferrandiz, et al. (2009). "Economic evaluation of a store-andforward teledermatology system for skin cancer patients." Journal of Telemedicine & Telecare 15(1): 40-45. We conducted an economic analysis of a store-and-forward teledermatology system for the routine triage of skin cancer patients. A cost-identification, costeffectiveness and sensitivity analysis under a societal perspective was used to compare teledermatology with the conventional care alternative. In the period March 2004 to July 2005, a total of 2009 teledermatology referrals were managed from 12 Primary Care Centres (PCCs) of the public health system. The unit cost was of Euro 79.78 per patient in teledermatology, and Euro 129.37 per patient in conventional care (P < 0.005), with an incremental cost of Euro 49.59 per patient in favour of teledermatology. The cost ratio between teledermatology and conventional care was 1.6. There was a significant inverse relation between the unit cost in each participating PCC and the number of teleconsultations transmitted from them (P < 0.001). Teledermatology resulted in a more costeffective, or dominant, methodology. In a public health system equipped with an

intranet, the routine use of teledermatology in skin cancer clinics is a costeffective method of managing referrals. Morgan, A. E., C. M. Lappan, et al. (2009). "Infectious disease teleconsultative support of deployed healthcare providers." Military Medicine 174(10): 1055-1060. Specialty teleconsultation is being provided to deployed healthcare providers in the current wars in Iraq and Afghanistan through the use of the Army Knowledge Online (AKO) e-mail service. We reviewed 374 teleconsults received by the infectious disease (ID) service between January 2005 and June 2008. The patients were 65% male, 12% female, 33% the gender was not stated or the consult did not involve an individual, and 41% were U.S. Army. The average response time was under 5 hours. Ninety-one percent of consults originated from the U.S. Central Command area of responsibility. Consults included questions pertaining to therapy (42%), diagnosis (21%), prevention (13%), or mixed categories (24%). Bacterial infections were the most common (32%), followed by parasitic infections (16%). Tuberculosis and methicillin-resistant Staphylococcus aureus accounted for 13% and 8% of consults, respectively. Data from this program should be useful in focusing predeployment provider training. It also provides the military ID community situational awareness of problems encountered in theater. Morgan, R. D., A. R. Patrick, et al. (2008). "Does the use of telemental health alter the treatment experience? Inmates' perceptions of telemental health versus face-to-face treatment modalities." Journal of Consulting & Clinical Psychology 76(1): 158-162. In corrections, where staffing limitations tax an overburdened mental health system, telemental health is an increasingly common mode of mental health service delivery. Although telemental health presents an efficient treatment modality for a spectrum of mental health services, it is imperative to study how this modality influences key elements of the treatment experience. In this study, the authors compared inmates' perceptions of the working alliance, postsession mood, and satisfaction with psychiatric and psychological mental health services delivered through 2 different modalities: telemental health and face-to-face. Participants consisted of 186 inmates who received mental health services (36 via telepsychology, 50 via face-to-face psychology, 50 via telepsychiatry, and 50 via face-to-face psychiatry). Results indicate no significant differences in inmates' perceptions of the work alliance with the mental health professional, postsession mood, or overall satisfaction with services when telemental health and face-toface modalities were compared within each type of mental health service. Implications of these findings are presented. Mullens, W., L. P. J. Oliveira, et al. (2010). "Insights from internet-based remote intrathoracic impedance monitoring as part of a heart failure disease management program." Congestive Heart Failure 16(4): 159-163. Changes in intrathoracic impedance (Z) leading to crossing of a derived fluid index (FI) threshold has been associated with heart failure (HF) hospitalization. The authors developed a remote monitoring program as part of HF disease

management and prospectively examined the feasibility and resource utilization of monitoring individuals with an implanted device capable of measuring Z. An HF nurse analyzed all transmitted data daily, as they were routinely uploaded as part of quarterly remote device monitoring, and called the patient if the FI crossed the threshold (arbitrarily defined at 60 Omega) to identify clinically relevant events (CREs) that occurred during this period (eg, worsening dyspnea or increase in edema or weight). A total of 400 uploads were completed during the 4-month study period. During this period, 34 patients (18%) had an FI threshold crossing, averaging 0.52 FI threshold crossings per patient-year. Thirty-two of 34 patients contacted by telephone (94%) with FI threshold crossing had evidence of CREs during this period. However, only 6 (18%) had HF hospitalizations, 19 (56%) had reported changes in HF therapy, and 13 (38%) reported drug and/or dietary plan nonadherence. The average data analysis time required was 30 min daily when focusing on those with FI threshold crossing, averaging 8 uploads for review per working day and 5 telephone follow-ups per week. Our pilot observations suggested that Internet-based remote monitoring of Z trends from existing device interrogation uploads is feasible as part of a daily routine of HF disease management. 2010 Wiley Periodicals, Inc. Muller, M., P. Loijens, et al. (2010). "Reducing hardware risks in the development of Telematic rescue assistance systems: a methodology." Conference Proceedings: ... Annual International Conference of the IEEE Engineering in Medicine & Biology Society 2010: 2163-2166. In developed countries many of the main causes of death such as heart attack and stroke usually strike outside of hospitals. Therefore patient outcome depends to a large extent on the quality of preclinical care. In order to improve it, Telematic Rescue Assistance Systems (TRAS) are being developed. They transmit vital signs, audio and sometimes video data from the rescue team to an emergency physician at a remote site, thus enabling this specialist to assist in diagnosis and treatment. Not only is specialist expertise brought to the emergency site, but also time to definite treatment is reduced, as specialists are involved earlier and hospitals are informed in advance about incoming patients. Due to their use in emergencies, risks to the proper functioning of TRAS hardware have to be kept as low as possible. Adequate methods for risk assessment have to be chosen, since the use of an inadequate method can result in a cumbersome resource-intensive process, while at the same time major risks are being overlooked. This paper proposes a methodology for reducing hardware risks in the development of TRAS. Muus K, K. A., Lancette S (2007). "Uncontrolled Diabetes Hospitalizations in the United States: A Rural/Urban Comparison. ." Abstr AcademyHealth Meet. the paper looked at admissions in rural settings. they found that diabetes prevelance was higher than urban setting and the patients were less likely to have completed care recommendations. 7% or a 16 times greater chance of diabetes in the rural setting.

Narenthiranathan, N. R., J. S. Adnan, et al. (2010). "Tailoring teleconsultation to meet the current needs of neurosurgical services: a multimodality oriented neurosurgical consultation." Studies in Health Technology & Informatics 161: 112-121. Teleconsultation in Neurosurgery was introduced in Malaysia in 2006 with the aims of enhancing quality services in the field of Neurosurgery. The present teleconsultation system is equipped with user friendly features which allow physicians to send and neurosurgeons to gain access to patient data in a swift and effective manner. In the past, teleconsultation in neurosurgery was tied with teleradiology, however we have now developed a multimodality system to cater specifically for neurosurgery. In Malaysia, the teleconsultation service is gaining momentum as evidenced by the large volume of cases channeled through this system. 944 cases within a span of 4 months were recorded on the system. 54.5% of the cases were trauma, 33.2% stroke, 6.1% intracranial tumours, 2% of cases were of spinal pathology, 2% pediatric anomalies and 2.2% intracranial infections. 50.2% of the referrals were after regular working hours reflecting the need for dedicated teleneurosurgery consultative services and the ability to review referrals outside of hospitals. Only 36% of cases needed emergency transfers and 9.9% of the cases were managed remotely at distant hospitals. Another 9.4% of the cases were either transferred electively or brought to the clinic for consultation. The above findings emphasise the importance of teleconsultation as a means to provide wide medical coverage within the region. Ng, M., N. Nathoo, et al. (2009). "Improving access to eye care: teleophthalmology in Alberta, Canada." Journal of Diabetes Science & Technology 3(2): 289-296. BACKROUND: Diabetic retinopathy in Alberta and throughout Canada is common, with a prevalence up to 40% in people with diabetes. Unfortunately, due to travel distance, time, and expense, a third of patients with diabetes do not receive annual dilated eye examinations by ophthalmologists, despite universal health care access. In an effort to improve access, a teleophthalmology program was developed to overcome barriers to eye care. Prior to clinical implementation, teleophthalmology technology was clinically validated for the identification of treatable levels of diabetic retinopathy. METHOD: Patients undergoing a teleophthalmology assessment underwent stereoscopic digital retinal photographs following pupillary dilation. Digital images were then packaged into an encrypted password-protected compressed file for uploading onto a secure server. Images were digitally unpackaged for review as a stereoscopic digital slide show and graded with a modified Early Treatment Diabetic Retinopathy Study algorithm. Reports were then generated automatically as a PDF file and sent back to the referring physician. Results: Teleophthalmology programs in Alberta have assessed more than 5500 patients (9016 visits) to date. Nine hundred thirty patients have been referred for additional testing or treatment. Approximately 2% of teleophthalmology assessments have required referral for in-person examination due to ungradable image sets, most commonly due to cataract, corneal drying, or asteroid hyalosis. CONCLUSIONS: In Alberta and

throughout Canada, many patients with diabetes do not receive an annual dilated eye examination. Teleophthalmology is beneficial because patients can be assessed within their own communities. This decreases the time to treatment, allows treated patients to be followed remotely, and prevents unnecessary referrals. Health care costs may be reduced by the introduction of comprehensive teleophthalmology examinations by enabling testing and treatment to be planned prior to the patient's first visit. (c) 2009 Diabetes Technology Society. Nielsen, P. S., J. Lindebjerg, et al. (2010). "Virtual microscopy: an evaluation of its validity and diagnostic performance in routine histologic diagnosis of skin tumors." Human Pathology 41(12): 1770-1776. Digitization of histologic slides is associated with many advantages, and its use in routine diagnosis holds great promise. Nevertheless, few articles evaluate virtual microscopy in routine settings. This study is an evaluation of the validity and diagnostic performance of virtual microscopy in routine histologic diagnosis of skin tumors. Our aim is to investigate whether conventional microscopy of skin tumors can be replaced by virtual microscopy. Ninety-six skin tumors and skintumor-like changes were consecutively gathered over a 1-week period. Specimens were routinely processed, and digital slides were captured on Mirax Scan (Carl Zeiss MicroImaging, Gottingen, Germany). Four pathologists evaluated the 96 virtual slides and the associated 96 conventional slides twice with intermediate time intervals of at least 3 weeks. Virtual slides that caused difficulties were reevaluated to identify possible reasons for this. The accuracy was 89.2% for virtual microscopy and 92.7% for conventional microscopy. All kappa coefficients expressed very good intra- and interobserver agreement. The sensitivities were 85.7% (78.0%-91.0%) and 92.0% (85.5%-95.7%) for virtual and conventional microscopy, respectively. The difference between the sensitivities was 6.3% (0.8%-12.6%). The subsequent reevaluation showed that virtual slides were as useful as conventional slides when rendering a diagnosis. Differences seen are presumed to be due to the pathologists' lack of experience using the virtual microscope. We conclude that it is feasible to make histologic diagnosis on the skin tumor types represented in this study using virtual microscopy after pathologists have completed a period of training. Larger studies should be conducted to verify whether virtual microscopy can replace conventional microscopy in routine practice. Copyright Copyright 2010 Elsevier Inc. All rights reserved. Nijland, N., K. Cranen, et al. (2010). "Patient use and compliance with medical advice delivered by a web-based triage system in primary care." Journal of Telemedicine & Telecare 16(1): 8-11. We studied a web-based triage system which was accessible to the general public in the Netherlands. In a retrospective analysis we investigated the type of complaints that were submitted and the kind of advice provided. Over a period of 15 months, 13,133 different people began using the web-based triage system and 3812 patients went right through the triage process to the end. The most

frequent complaints were common cold symptoms, such as cough and a sore throat (22%), itch problems (13%), urinary complaints (12%), diarrhoea (10%), headache (8%) and lower back pain (8%). Most commonly, the system generated the advice to contact a doctor (85%) and in 15% of the cases the system provided fully automated, problem-tailored, self-care advice. A total of 192 patients participated in a prospective study and completed an online survey immediately after the delivery of advice. A follow-up questionnaire on actual compliance was completed by 35 patients. Among these, 20 (57%) had actually complied with the advice provided by the system. A regression analysis revealed that intention to comply was strongly related to actual compliance. In turn, intention to comply was strongly related to attitude towards the advice (P < 0.001). Web-based triage can contribute to a more efficient primary care system, because it facilitates the gatekeeper function. Nijland, N., J. E. W. C. van Gemert-Pijnen, et al. (2009). "Increasing the use of econsultation in primary care: results of an online survey among non-users of econsultation." International Journal of Medical Informatics 78(10): 688-703. OBJECTIVE: To identify factors that can enhance the use of e-consultation in primary care. We investigated the barriers, demands and motivations regarding e-consultation among patients with no e-consultation experience (non-users). METHODS: We used an online survey to gather data. Via online banners on 26 different websites of patient organizations we recruited primary care patients with chronic complaints, an important target group for e-consultation. A regression analysis was performed to identify the main drivers for e-consultation use among patients with no e-consultation experience. RESULTS: In total, 1706 patients started to fill out the survey. Of these patients 90% had no prior e-consultation experience. The most prominent reasons for non-use of e-consultation use were: not being aware of the existence of the service, the preference to see a doctor and e-consultation not being provided by a GP. Patients were motivated to use econsultation, because e-consultation makes it possible to contact a GP at any time and because it enabled patients to ask additional questions after a visit to the doctor. The use of a Web-based triage application for computer-generated advice was popular among patients desiring to determine the need to see a doctor and for purposes of self-care. The patients' motivations to use econsultation strongly depended on demands being satisfied such as getting a quick response. When looking at socio-demographic and health-related characteristics it turned out that certain patient groups - the elderly, the lesseducated individuals, the chronic medication users and the frequent GP visitors were more motivated than other patient groups to use e-consultation services, but were also more demanding. The less-educated patients, for example, more strongly demanded instructions regarding e-consultation use than the highly educated patients. CONCLUSION: In order to foster the use of e-consultation in primary care both GPs and non-users must be informed about the possibilities and consequences of e-consultation through tailored education and instruction. We must also take into account patient profiles and their specific demands regarding e-consultation. Special attention should be paid to patients who can

benefit the most from e-consultation while also facing the greatest chance of being excluded from the service. As health care continues to evolve towards a more patient-centred approach, we expect that patient expectations and demands will be a major force in driving the adoption of e-consultation. Nikus, K., J. Lahteenmaki, et al. (2009). "The role of continuous monitoring in a 24/7 telecardiology consultation service--a feasibility study." Journal of Electrocardiology 42(6): 473-480. Today's coronary care unit patients include those with complicated and uncomplicated myocardial infarction, decompensated heart failure and frank cardiogenic shock, severe valvular heart disease, high-grade conduction disturbances, and incessant ventricular arrhythmias. Increasingly in modern medicine, these conditions are not seen in isolation but rather in connection with a series of additional medical comorbidities. Increased life expectancy results in an increase in the prevalence of chronic cardiovascular diseases and an increased demand for health care services. Telemedicine is the provision of health care services, through the use of information and communication technology, in situations where the health care professional and the patient, or 2 health care professionals, are not in the same location. It involves the secure transmission of medical data and information, through text, sound, images, or other forms needed for the prevention, diagnosis, treatment, and follow-up of a patient. Telecardiology is one of the oldest applications in telemedicine and has been largely applied during the last 10 to 20 years. This study evaluated the feasibility of remote surveillance of coronary care unit and cardiology ward patient monitoring data by a "telecardiologist" with access to electronic health care record data and digitally stored 12-lead electrocardiograms. The remote access to the hospital intranet proved to be technically feasible. Also, the server applications used over the remote connection proved to be reliable and showed robustness against network performance variations. Extending remote patient surveillance to other hospitals is possible, provided that similar electrocardiogram and electronic health care record applications are available and a remote access can be arranged to them. However, the usability from cardiologist's perspective may be degraded if connecting with multiple applications and hospital networks is needed. The study indicated potential for speeding up the diagnostic and therapeutic processes in the hospital, although the study was limited in that the telecardiologist played a passive role and did not acutely impact patient care. In the future, the system could be expanded to surveillance of smaller hospitals. Telemedicine has the potential to aid in solving the conflict between aging of population, rise in the demand for critical care services, and shortage of professional personnel. This might, however, require a more active remote surveillance than the one tested in this study. Privacy- and security-related aspects are major components of building trust and confidence in telemedicine systems. In telecardiology, the real-time interactive telemedicine model with 24/7 service has potential superior performance compared with a store-and-forward telemedicine model.

Nilsen, L. L. and A. Moen (2008). "Teleconsultation - collaborative work and opportunities for learning across organizational boundaries." Journal of Telemedicine & Telecare 14(7): 377-380. Over a period of five months we observed teleconsultations between general practitioners (GPs) in community care and specialists in hospitals in two Norwegian health regions (A and B). In total, 47 teleconsultations between GPs and specialists were recorded. In region A, teleconsultations were organized when needed to discuss specific medical problems. In region B, teleconsultations took place during the specialists' daily morning meeting. The teleconsultations lasted for 5-40 min. There were three categories of talk. In the first two there was information exchange for patient updates and practical organization of the service. The third category, consultation, was the communicative process in which the GP and the specialist engaged in collaborative work, primarily discussing medical problems related to decision-making in patient care. Regular use of teleconsultation opens access to different repertoires of knowledge and experience, and brings knowledge to the point of patient care and medical decision-making. Ohashi, K., N. Sakamoto, et al. (2008). "Development of a telediagnosis endoscopy system over secure internet." Methods of Information in Medicine 47(2): 157-166. OBJECTIVES: We developed a new telediagnosis system to securely transmit high-quality endoscopic moving images over the Internet in real time. This system would enable collaboration between physicians seeking advice from endoscopists separated by long distances, to facilitate diagnosis. METHODS: We adapted a new type of digital video streaming system (DVTS) to our teleendoscopic diagnosis system. To investigate its feasibility, we conducted a two-step experiment. A basic experiment was first conducted to transmit endoscopic video images between hospitals using a plain DVTS. After investigating the practical usability, we incorporated a secure and reliable communication function into the system, by equipping DVTS with "TCP2", a new security technology that establishes secure communication in the transport layer. The second experiment involved international transmission of teleendoscopic image between Hawaii and Japan using the improved system. RESULTS: In both the experiments, no serious transmission delay was observed to disturb physicians' communications and, after subjective evaluation by endoscopists, the diagnostic qualities of the images were found to be adequate. Moreover, the second experiment showed that "TCP2-equipped DVTS" successfully executed high-quality secure image transmission over a long distance network. CONCLUSIONS: We conclude that DVTS technology would be promising for teleendoscopic diagnosis. It was also shown that a high quality, secure teleendoscopic diagnosis system can be developed by equipping DVTS with TCP2. Otto, C., J.-M. Comtois, et al. (2010). "The Martian chronicles: remotely guided diagnosis and treatment in the Arctic Circle." Surgical Endoscopy 24(9): 2170-2177. BACKGROUND: Despite rigorous health screening in astronaut crews, there are

a number of conditions that may occur during long duration, exploration class spaceflight. The risk of abdominal conditions requiring surgical intervention is not clear, yet submarine and polar base experiences suggest contingency planning is warranted. While radio communication time delay is only 2 s to the international space station (ISS), a potential Mars mission would necessitate time delays of about 15 min. We sought to demonstrate the feasibility of remote expert guidance of diagnostic ultrasound followed by laparoscopic appendectomy in a simulated Mars environment. METHODS: Research was deemed exempt by the institutional review board. A simulated Mars research environment was utilized on Devon Island in the Canadian Arctic. Electronic communications including audio and video were established between the Arctic base and Henry Ford Hospital serving as Mission Control and incorporated the 15-min communications lag into all communication. Ultrasound and laparoscopic capabilities were integrated into communications for remote guidance. Remote guidance methods and technology utilized has been previously published in communication with the ISS. A simulated scenario involving a young female astronaut developing right lower quadrant pain was developed and utilized for this demonstration. An anatomical appendectomy model was utilized for the ultrasound and laparoscopic portions. Reference aids describing background technical aspects were developed. A set of confirmation milestones was used to generate a hard stop and mandated remote review. RESULTS: The simulated appendectomy was successfully pursued on the first attempt with no delays or untoward events. Reference aids were appropriate for non-surgical personnel and hard stops for milestones with remote approval and go ahead were shown to be feasible. The appendicitis was appropriately diagnosed utilizing remote guidance of ultrasonography and the appendix removed laparoscopically using stapled technique with remote guidance as well. CONCLUSIONS: We report a successful remote guidance demonstration from a simulated mars environment with clinical control from a terrestrial base utilizing appropriate delay and consistent bandwidth and technology. Padman, R., G. Shevchik, et al. (2010). "eVisit: a pilot study of a new kind of healthcare delivery." Studies in Health Technology & Informatics 160(Pt 1): 262-266. Patient online eVisits are gaining momentum due to increasing consumer demand for improved access to clinical services, availability of new technologies to deploy such services and development of reimbursement initiatives by major payers. The eVisit service provides patients with an online consultation through a series of structured, secure message exchanges with a physician, providing an alternative for onsite office visits and non-reimbursed phone-based care. In this study, we evaluate a pilot deployment of eVisits in a primary care clinic providing online consultation service for 7 simple health conditions at its three locations. We examine usage data over 3 months and survey and interview results for trends in adoption, demographic and temporal patterns of usage, clinician and patient expectations and experiences, and challenges to sustainability of the service. Based on our analysis, we conclude that the eVisit pilot was a success. Patients valued the new service being offered as demonstrated by a rapid

increase in usage. The quality of service was good with fast turnaround times and few exchanges to resolve a request. These positive outcomes combined with a reimbursement model are promising indications of sustainability but several challenges remain. Pakyurek, M., P. Yellowlees, et al. (2010). "The child and adolescent telepsychiatry consultation: can it be a more effective clinical process for certain patients than conventional practice?" Telemedicine Journal & E-Health 16(3): 289-292. The literature on the efficacy of telepsychiatry for assessing and treating children and adolescents with mental health problems is still developing, but there is evidence that telepsychiatry is diagnostically valid, and that there is high patient and provider satisfaction. Outcome studies are awaited, with the assumption that telepsychiatry has to demonstrate at least as good outcomes and reliability as face-to-face psychiatric care. In this article we suggest, by reviewing the process of telepsychiatry with children, and illustrating relevant issues with five case studies of patients we have seen, that there is a valid case for arguing that in certain children and adolescents, telepsychiatry, as a consultation process, might actually be a superior method of psychiatric assessment to face-to-face consultation. Four factors stand out supporting this view. These are the novelty of the consultation, the capacity to provide direction, the extra distance involved (both psychological and physical), and the authenticity of the interaction. More research in child and adolescent telepsychiatry is indicated. Pan, E., C. Cusack, et al. (2008). "The value of provider-to-provider telehealth." Telemedicine Journal & E-Health 14(5): 446-453. Telehealth has great potential to improve access to care, but its adoption in routine healthcare has been slow. The lack of clarity about the value of telehealth implementations has been one reason cited for this slow adoption. The Center for Information Technology Leadership has examined the value of telehealth encounters in which there is a provider both with the patient and at a distance from the patient. We considered three models of telehealth: store-and-forward, real-time video, and hybrid systems. Evidence from the literature was extrapolated using a computer simulation, which found that the hybrid model was the most cost effective. The simulation predicted savings of $4.3 billion per year if hybrid telehealth systems were implemented in emergency rooms, prisons, nursing home facilities, and physician offices across the United States. We also conducted a sensitivity analysis to determine which factors most influence costs and savings. Payers, providers, and policymakers should work together to remove the barriers to the adoption of telehealth so that this cost savings can be realized in the U.S. healthcare system. [References: 40] Pappas, G. (2010). "Planning for Internet connectivity in remote patient monitoring." Telemedicine Journal & E-Health 16(5): 639-641. It is important for healthcare organizations to understand the requirements and challenges of logistics when deploying remote patient monitoring (RPM) technologies in patient homes. Although most organizations prepare thoroughly

for the clinical and work flow aspect of RPM solutions, they neglect to consider the logistical resources necessary to successfully manage a broad deployment. The term "logistics" in this context refers to the processes and infrastructure required to enable the use of RPM technologies in the patient's home. This article has been generated from the findings and observations of several studies where logistical objectives were included in the protocol in addition to the conventional metrics of clinical outcome, satisfaction, and economic measures. These studies implemented several high-speed Internet connectivity models with the use of wired broadband, 3G wireless, or a combination. The organizations that utilized 3G to provide Internet connectivity experienced significantly fewer logistical issues and patient frustration. It was also observed that regardless of the model, each of the clinical partners in these studies were not adequately prepared to manage Internet connectivity. Because of this, all experienced some level of difficulty installing and supporting RPM devices in the home. Park, E. S., B. H. Boedeker, et al. (2011). "The initiation of a preoperative and postoperative telemedicine urology clinic." Studies in Health Technology & Informatics 163: 425-427. This work describes the establishment of a Telemedicine Urology Clinic at the VA Medical Center in Omaha, Nebraska to serve an underserved veteran population in rural Nebraska. Results from patient satisfaction surveys show that both the patient and the healthcare provider benefit from the telemedicine encounter for both the preoperative and the postoperative setting. Park, H.-S., Q. Peng, et al. (2008). "A portable telerehabilitation system for remote evaluations of impaired elbows in neurological disorders." IEEE Transactions on Neural Systems & Rehabilitation Engineering 16(3): 245-254. A portable teleassessment system was designed for remote evaluation of elbow impairments in patients with neurological disorders. A master device and a slave device were used to drive a mannequin arm and the patient's arm, respectively. The elbow flexion angle and torque were measured at both the master and slave devices, and sent to each other for teleoperation. To evaluate spasticity/contracture of the patient's elbow remotely, the clinician asked the patient to relax the elbow, moved the mannequin arm at a selected velocity, and haptically felt the resistance from the patient's elbow. In other tasks, the patient moved his/her elbow voluntarily and the clinician observed the corresponding mannequin arm movement and determined the active range of motion (ROM). The clinician could also remotely resist the patient's movement and evaluate the muscle strength. To minimize the effect of network latency, two different teleoperation schemes were used depending on the speed of the tasks. For slow movement tasks, real-time teleoperations were performed using control architectures that considered causality of the tasks, with performance similar to that during an in-person examination. For tasks involving fast movements, a teach-and-replay teleoperation scheme was used which provided the examiner with transparent and stable haptic feeling. Overall, the teleassessment system allowed the clinician to remotely evaluate the impaired elbow of stroke survivors,

including assessment of the passive ROM, active ROM, muscle strength, velocity-dependent spasticity, and catch angle. Pearce, C., P. Kumarpeli, et al. (2010). "Getting seamless care right from the beginning - integrating computers into the human interaction." Studies in Health Technology & Informatics 155: 196-202. BACKGROUND: The digital age is coming to the health space, behind many other fields of society. In part this is because health remains heavily reliant on human interaction. The doctor-patient relationship remains a significant factor in determining patient outcomes. Whilst there are many benefits to E-Health, there are also significant risks if computers are not adequately integrated into this interaction and accurate data are consequently not available on the patient's journey through the health system. METHOD: Video analysis of routine clinical consultations in Australian and UK primary care. We analyzed 308 consultations (141+167 respectively) from these systems, with an emphasis on how the consultation starts. RESULTS: Australian consultations have a mean duration of 12.7 mins, UK 11.8 mins. In both countries around 7% of consultations are computer initiated. Where doctors engaged with computer use the patient observed the computer screen much more and better records were produced. However, there was suboptimal engagement and poor records and no coding in around 20% of consultations. CONCLUSIONS: How the computer is used at the start of the consultation can set the scene for an effective interaction or reflect disengagement from technology and creation of poor records. Pereira-Monteiro, J., M.-M. Wysocka-Bakowska, et al. (2010). "Guidelines for telematic second opinion consultation on headaches in Europe: on behalf of the European Headache Federation (EHF)." Journal of Headache & Pain 11(4): 345-348. The seeking of a second opinion is the long-established process whereby a physician or expert from the same or a similar specialty is invited to assess a clinical case in order to confirm or reject a diagnosis or treatment plan. Seeking a second opinion has become more common in recent years, and the trend is associated with significant changes in the patient-doctor relationship. Telemedicine is attractive because it is not only fast but also affordable and thus makes it possible to reach highly qualified centres and experts that would otherwise be inaccessible, being impossible, or too expensive, to reach by any surface transport. In Europe, the European Headache Federation (EHF), being able to draw on a group of headache experts covering all the European languages, is the organisation best placed to provide qualified second-opinion consultation on difficult headache cases and to develop a Headache Medical Opinion Service Centre. The provision of good quality clinical information is crucial to the formulation of a valid, expert second opinion. This preliminary step can be properly accomplished only by the primary health care provider through the furnishing of an appropriate clinical report, together with the results of all available tests, including original films of all imaging studies already performed. On receiving the EHF's proposed standardised data collection form, properly filled in, we may be sure that we have all the relevant data necessary to

formulate a valid expert second opinion. This form can be accessed electronically and downloaded from the EHF website. Once finalised, the EHF second opinion project should be treated as a pilot strategy that requires careful monitoring (for the first year at least), so that appropriate changes, as suggested by the retrospective analysis and its quality control, can be implemented. Pflug, B., P. Kumarapeli, et al. (2010). "Measuring the impact of the computer on the consultation: an open source application to combine multiple observational outputs." Informatics for health & social care 35(1): 10-24. A diverse range of tools and techniques can be used to observe the clinical consultation and the use of information technology. These technologies range from transcripts; to video observation with one or more cameras; to voice and pattern recognition applications. Currently, these have to be observed separately and there is limited capacity to combine them. Consequently, when multiple methods are used to analyse the consultation a significant proportion of time is spent linking events in one log file (e.g. mouse movements and keyboard use when prescribing alerts appear) with what was happening in the consultation at that time. The objective of this study was to develop an application capable of combining and comparing activity log-files and with facilities to view simultaneously all data relating to any time point or activity. Interviews, observations and design prototypes were used to develop a specification. Class diagram of the application design was used to make further development decisions. The application development used object-orientated design principles. We used open source tools; Java as the programming language and JDeveloper as the development environment. The final output is log file aggregation (LFA) tool which forms part of the wider aggregation of log files for analysis (ALFA) open source toolkit ( www.biomedicalinformatics.info/alfa/ ). Testing was done using sample log files and reviewed the application's utility for analysis of the consultation activities. Separation of the presentation and functionality in the design stage enabled us to develop a modular and extensible application. The application is capable of converting and aggregating several log files of different formats and displays them in different presentation layouts. We used the Java Media Framework to aggregate video channels. Java extensible mark-up language (XML) package facilitated the conversion of aggregated output into XML format. Analysts can now move easily between observation tools and find all the data related to an activity. The LFA application makes new analysis tasks feasible and established tasks much more efficient. Researchers can now store multiple log file data as a single file isolate and investigate different doctorcomputer-patient interaction. Phabphal, K. and S. Hirunpatch (2008). "The effectiveness of low-cost teleconsultation for emergency head computer tomography in patients with suspected stroke." Journal of Telemedicine & Telecare 14(8): 439-442. Teleradiology in an emergency situation can be used to support rapid neurological decision-making when specialists are remote from the hospital concerned. We have developed a low-cost system using a PDA phone as the

receiving equipment. The experimental system was based on a notebook PC to send the images and a PDA phone to receive them. We used commercially available toolbar software for transmitting the information through the mobile phone network. A total of 100 images from clinically suspected strokes within the previous 24 hours were transmitted to a neurologist. The mean size of the original picture was 20.9 kByte and the images were compressed by approximately 2:1 before transmission. The mean transmission time was 48 s per image. The diagnosis from the PDA phone image was in complete agreement with the diagnosis from the original image in cases of acute ischaemic stroke, intracerebral haemorrhage, metastasis and in normal scans. However, there was agreement in only 7 of the 8 cases (88%) of subarachnoid haemorrhage. The overall transmission cost was 400 Thai baht per case. The study showed that good accuracy can be achieved with a low-cost system for teleradiology consultation in stroke. Pico, L. E. A., O. R. Cuenca, et al. (2008). "Knowledge management model for teleconsulting in telemedicine." Studies in Health Technology & Informatics 137: 130140. The present article shows a study about requirements for teleconsulting in a telemedicine solution in order to create a knowledge management system. Several concepts have been found related to the term teleconsulting in telemedicine which will serve to clear up their corresponding applications, potentialities, and scope. Afterwards, different theories about the art state in knowledge management have been considered by exploring methodologies and architectures to establish the trends of knowledge management and the possibilities of using them in teleconsulting. Furthermore, local and international experiences have been examined to assess knowledge management systems focused on telemedicine. The objective of this study is to obtain a model for developing teleconsulting systems in Colombia because we have many healthinformation management systems but they don't offer telemedicine services for remote areas. In Colombia there are many people in rural areas with different necessities and they don't have medicine services, teleconsulting will be a good solution to this problem. Lastly, a model of a knowledge system is proposed for teleconsulting in telemedicine. The model has philosophical principles and architecture that shows the fundamental layers for its development. Polisena, J., K. Tran, et al. (2009). "Home telehealth for diabetes management: a systematic review and meta-analysis." Diabetes, Obesity & Metabolism 11(10): 913930. AIM: It is estimated that more than 180 million people worldwide have diabetes. Health-care providers can remotely deliver health services to this patient population using information and communication technology, also known as home telehealth. Home telehealth may be classified into two subtypes: home telemonitoring (HTM) and telephone support (TS). The research objective was to systematically review the literature and perform meta-analyses to assess the potential benefits of home telehealth compared with usual care (UC) for patients

with diabetes. METHODS: An electronic literature search was conducted to identify studies on home telehealth and patients with diabetes that were published between 1998 and 2008 using Medline, Medline In-Process & Other Non-Indexed Citations, BIOSIS Previews and EMBASE. RESULTS: Twenty-six studies (n = 5069 patients) on home telehealth for diabetes were selected. Twenty-one studies evaluated HTM and 5 randomized controlled trials assessed TS. HTM had a positive effect on glycaemic control [as measured by lower glycated haemoglobin level] compared with UC (weighted mean difference =0.21; 95% confidence interval -0.35 to -0.08), but the results were mixed for TS. Study results indicated that home telehealth helps to reduce the number of patients hospitalized, hospitalizations and bed days of care. Home telehealth was similar or favourable to UC across studies for quality-of-life and patient satisfaction outcomes. CONCLUSIONS: In general, home telehealth had a positive impact on the use of numerous health services and glycaemic control. More studies of higher methodological quality are required to give more precise insights into the potential clinical effectiveness of home telehealth interventions. Przybylski, A., J. Zakrzewska-Koperska, et al. (2009). "Technical and practical aspects of remote monitoring of implantable cardioverter-defibrillator patients in Poland preliminary results." Kardiologia Polska 67(5): 505-511. BACKGROUND: The aim of remote monitoring of implantable cardioverterdefibrillators (ICD) is to increase the patient's safety by early detection of technical or medical malfunctions and decrease the number of follow-up visits. AIM: To evaluate the feasibility and reliability of internet-based home monitoring of ICD recipients in Poland. METHODS: Twenty-seven patients with ICD with remote monitoring options were evaluated; 20 (74%) patients had a single chamber ICD, 6 (22%) patients had a dual chamber ICD and one had an ICD with a resynchronisation therapy option. Medical and technical events reported by the remote monitoring system as well as interruptions in monitoring longer than 14 days were analysed. RESULTS: The patients were followed for 12.7 +/10.5 months. Two of them died because of heart failure (6 and 13 months after ICD implantation, respectively). The remote monitoring system reported medical events in 13 (48%) patients. In total, we received 32 event reports (from 1 to 19 per patient, mean 2.6) which were generated due to the detection of ventricular tachycardia (VT) (17 events in 9 patients), ventricular fibrillation (VF) (9 episodes in 6 patients), ineffective defibrillation with the maximal energy (5 reports in 3 patients) and supraventricular tachycardia in the VT detection window (1). Two patients had more than 3 VT/VF episodes during 24 h. There were no reports on technical abnormalities of the ICD system. Interruptions in home monitoring longer than 14 days occurred in 5 (18.5%) patients and lasted 2 to 14 weeks (mean 2.8 +/- 7.1). The longest break was caused by the patient's stay abroad. The remaining interruptions were caused by: journeys (5 episodes), hospitalisations (4), and a temporary stay in a place without sufficient GSM coverage (3). During the follow-up period there were no interruptions in monitoring caused by transmitter or ICD failure. All data received by the home monitoring system were confirmed during the follow-up visits. CONCLUSION:

Remote monitoring of ICD recipients in Poland does not present technical difficulties and enables early detection of serious events in ICD patients. Raatikainen, M. J. P., P. Uusimaa, et al. (2008). "Remote monitoring of implantable cardioverter defibrillator patients: a safe, time-saving, and cost-effective means for follow-up." Europace 10(10): 1145-1151. AIMS: The purpose of this prospective study was to investigate whether internetbased remote monitoring offers a safe, practical, and cost-effective alternative to the in-office follow-up visits of patients with an implantable cardioverter defibrillator (ICD). METHODS AND RESULTS: Forty-one patients (62 +/- 10 years, range 41-76, 83% male) with previously implanted ICD were followed for 9 months. One-hundred and nineteen scheduled and 18 unscheduled data transmissions were performed. There were no device-related adverse events. Over 90% of the patients found the system easy to use. Physicians reported the system as being 'very easy' or 'easy' to use and found the data comparable to traditional device interrogation in 99% of the cases. They were able to address all unscheduled data transmissions remotely. Compared with the in-office visits, remote monitoring required less time from patients (6.9 +/- 5.0 vs. 182 +/- 148 min, P < 0.001) and physicians (8.4 +/- 4.5 vs. 25.8 +/- 17.0 min, P < 0.001) to complete the follow-up. Substitution of two routine in-office visits during the study by remote monitoring reduced the overall cost of routine ICD follow-up by 524 euro per patient (41%). CONCLUSION: Remote monitoring offers a safe, feasible, time-saving, and cost-effective solution to ICD follow-up. Rabinowitz, T., K. M. Murphy, et al. (2010). "Benefits of a telepsychiatry consultation service for rural nursing home residents." Telemedicine Journal & E-Health 16(1): 3440. Psychiatric care for nursing home residents is difficult to obtain, especially in rural areas, and this deficiency may lead to significant morbidity or death. Providing this service by videoconference may be a helpful, cost-effective, and acceptable alternative to face-to-face treatment. We analyzed data for 278 telepsychiatry encounters for 106 nursing home residents to estimate potential cost and time savings associated with this modality compared to in-person care. A total of 843.5 hours (105.4 8-hour work days) of travel time was saved compared to inperson consultation for each of the 278 encounters if they had occurred separately. If four resident visits were possible for each trip, the time saved would decrease to 26.4 workdays. Travel distance saved was 43,000 miles; 10,750 miles if four visits per trip occurred. More than $3,700 would be spent on gasoline for 278 separate encounters; decreased to $925 for four visits per roundtrip. Personnel cost savings estimates ranged from $33,739 to $67,477. Physician costs associated with additional travel time ranged from $84,347 to $253,040 for 278 encounters, or from $21,087 to $63,260 for four encounters per visit. The telepsychiatry approach was enthusiastically accepted by virtually all residents, family members, and nursing home personnel, and led to successful patient management. Providing psychiatric care to rural nursing home residents by videoconference is cost effective and appears to be a medically acceptable

alternative to face-to-face care. In addition, this approach will allow many nursing homes to provide essential care that would not otherwise be available. Rand, E. R., C. M. Lappan, et al. (2009). "Paging the worldwide cardiology consultant: the Army Knowledge Online Telemedicine Consultation Program in cardiology." Military Medicine 174(11): 1144-1148. BACKGROUND: Global operations place large numbers of military and nonmilitary personnel in austere environments. Aeromedical evacuation for cardiovascular issues is periodically required. The Army Knowledge Online (AKO) Telemedicine Consultation Program was initiated by the Office of the Surgeon General to electronically link deployed medical providers with subspecialty consultants to assist and guide triage and disposition. METHODS: Electronic consultation triggered a text page to an on-call staff cardiologist at Brooke Army Medical Center. Cardiology teleconsultations for the first 3.5 years were analyzed. RESULTS: Two hundred seven cardiology teleconsults were managed, with an average response time of 4 hours 54 minutes. The three most prevalent reasons for teleconsultation were electrocardiographic abnormalities, chest pain syndromes, and syncope. Six evacuations were avoided; 29 evacuations were facilitated. An estimated $144,000 was saved, plus intangible benefits. CONCLUSIONS: Cardiology teleconsultation provides a valuable service to deployed providers, decreases medical evacuation costs, and facilitates transfer of patients to appropriate facilities. Ray, P., N. Parameswaran, et al. (2008). "Awareness modelling in collaborative mobile e-health." Journal of Telemedicine & Telecare 14(7): 381-385. E-health based on mobile wireless networks is called mobile e-health. Mobile ehealth can facilitate computer-supported cooperative work, which encompasses tasks from email and instant messaging to wireless information sharing through broadband and telecommunication networks. In the development of cooperative management systems, the concept of 'awareness level' has been introduced. This is based on factors such as the location and actions of the user involved. Mobile e-health can help to achieve cooperation by providing the right awareness levels at the right time. The improved awareness levels allow health professionals to provide patient care with better quality and efficiency. Mobile ehealth systems have the potential to take over the mundane tasks of the doctor so that better quality health services can be provided. Richard A. Raymond, M. D. (2010). "Rural 2010 Health Goals and Objectives for Nebraska." NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM. Paper looked at Nebraska's experience with rural care and specifically cited how rural patients are affected with diabetes, cancer, etc differently than urban locations. Richter, G. M., S. L. Williams, et al. (2009). "Telemedicine for retinopathy of prematurity diagnosis: evaluation and challenges." Survey of Ophthalmology 54(6): 671-685. Retinopathy of prematurity (ROP) is a vasoproliferative disorder affecting low

birth weight infants. Although timely diagnosis and treatment can significantly reduce the risk of severe complications, ROP remains a leading cause of childhood blindness worldwide. Limitations of current disease management strategies include extensive travel and logistical coordination requirements for ophthalmologists and neonatologists, decreasing availability of adequately trained ophthalmologists at the point of care, variability in how retinal findings are diagnosed and documented, and a growing need for ROP care worldwide. Storeand-forward telemedicine is an emerging technology by which medical data are captured for subsequent interpretation by a remote expert. This has potential to improve accessibility, quality, and cost of ROP management. In this article, we summarize the current evaluation data on applications of telemedicine for ROP, particularly involving the diagnostic accuracy and reliability of remote image interpretation by experts. We also address challenges such as the costeffectiveness of telemedicine, and highlight potential barriers to implementation of these systems. Understanding these principles is essential to determine future directions in research and development of telemedicine systems for ROP, as well as for other ophthalmic diseases. [References: 80] Riper, H., G. Andersson, et al. (2010). "Theme issue on e-mental health: a growing field in internet research." Journal of Medical Internet Research 12(5): e74. This theme issue on e-mental health presents 16 articles from leading researchers working on systems and theories related to supporting and improving mental health conditions and mental health care using information and communication technologies. In this editorial, we present the background of this theme issue, and highlight the content of this issue. Robaldo, A., N. Rousas, et al. (2010). "Telemedicine in vascular surgery: clinical experience in a single centre." Journal of Telemedicine & Telecare 16(7): 374-377. Over a three-year period we performed 630 carotid endarterectomy procedures in 588 patients. From these we selected 90 patients (group A) who fulfilled the criteria for discharge one day after surgery. These patients were given an electronic blood pressure meter, a video phone for use at home and an antihypertensive drug (amlodipine). Using web-based video conferencing, we monitored the patients every 4 hours for the first two days. The other 498 patients (group B) were discharged on the second postoperative day. There were no significant differences between the groups in demographic characteristics, risk factors, carotid lesions, operative time, postoperative complications or blood loss. No cervical hematomas developed in group A. No patients needed to be readmitted because of major complications relating to the carotid endarterectomy. During the video-communication, 28 patients (31%) with a hypertensive crisis were treated by administration of amlodipine. At discharge, a questionnaire showed that there was a feeling of insecurity in both groups: 87% in group A vs. 79% in group B (P > 0.05). In group A, insecurity decreased after the first video connection and disappeared after the 8th day postoperatively. Telemedicine appears feasible and useful in carotid endarterectomy and may have other applications in vascular surgery care.

Rothenberg, S. S., S. Yoder, et al. (2009). "Initial experience with surgical telementoring in pediatric laparoscopic surgery using remote presence technology." Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A 19 Suppl 1: S219-222. PURPOSE: To evaluate the efficacy of remote presence technology in surgical mentoring. METHODS: A self-propelled robot, which is controlled from a wireless remote control station (Laptop computer)and provides two-way audio and visual communication, was used to allow an experienced endoscopic surgeon to provide mentoring during three unique laparoscopic cases. This first was a laparoscopic exploration in a 9-month-old child with clinical evidence of intermittent obstruction but nondiagnostic imaging studies.The second was a 4day-old, 3-kg infant with a congenital diaphragmatic hernia, and the third was a 1-day-old child with duodenal atresia. The robot was used to visualize the patient and radiologic studies, telestrate suggestions for trocar placement, visualize the laparoscopic procedure, and provide advice during the procedure.In the second case, another surgeon at a remote site control station watched the surgery and asked questions. RESULTS: The procedures were completed successfully in 90, 30, and 90 minutes. The first case included identification of the obstructing lesion (internal jejunal polyp) and intestinal resection and anastomosis. The second case involved resection of the hernia sac and repair of the congenital diaphragmatic hernia. The third consisted of identification of the site of atresia and identification of the site for the proximal and distal enterotomy. The robot allowed excellent visualization of the procedures and direct communication between the surgeon and mentor was uninterrupted throughout the case. Both surgeon and mentor felt the telementoring assisted in the case. CONCLUSIONS: While this is a limited series, the initial evaluation of this remote presence technology in the operating room suggests that it may be extremely usefully in adding surgical experience and expertise in minimally invasive surgery. Russell, T., P. Truter, et al. (2010). "The diagnostic accuracy of telerehabilitation for nonarticular lower-limb musculoskeletal disorders." Telemedicine Journal & E-Health 16(5): 585-594. OBJECTIVE: Musculoskeletal conditions are highly prevalent and disabling, particularly in rural and remote areas. In these areas, access to rehabilitation services is limited by the availability of physical therapists. Telerehabilitation may be a feasible solution to the issue of rural physical therapy service access; however, there is little existing evidence for clinical efficacy. The aim of this study was to establish the criterion validity and reliability of remote physical assessment and diagnosis of nonarticular lower limb musculoskeletal conditions via telerehabilitation. MATERIALS AND METHODS: Nineteen participants with existing nonarticular lower limb musculoskeletal conditions were assessed by a face-to-face therapist and a remote therapist to establish criterion validity of telerehabilitation. Video recordings from the telerehabilitation session were reviewed after 1 month by the remote therapist to establish intrarater reliability and by a second remote therapist to establish interrater reliability. Pathoanatomical diagnoses, system diagnoses, and the findings of the physical

examination were compared statistically. RESULTS: There was 79% or higher primary diagnosis agreement (same or similar diagnoses) and 79% or higher exact system diagnosis agreement for validity, intrarater reliability, and interrater reliability studies. The physical examination findings showed substantial agreement (0.61 < kappa < 0.80) in the validity study and almost perfect agreement (0.81 < kappa < 1.00) in the intrarater and interrater reliability studies. CONCLUSIONS: Using telerehabilitation for musculoskeletal physical therapy assessment of nonarticular lower limb conditions was found to be valid and reliable. Existing diagnostic reasoning can be applied; however, new methods of patient self-examination are needed to enable differential diagnosis. Ryskal, O., M. Muschinskaja, et al. (2010). "Telemicroscopic conferences for children of the Perm territory with suspected or proven malignant solid tumors." Klinische Padiatrie 222(3): 199-202. BACKGROUND: Malignant solid tumors are rare events in childhood and adolescence. Therefore central review of the histology and standardized grading are requested for accurate risk estimation and facilitate a tumor risk adapted treatment. AIMS OF THE STUDY: To abandon the time consuming transportation of tumor material over long distances to the specialized institution by implementation of an internet based consultation system. METHODS: A microscope combined with a videocamera (situated in Perm) and the personal computers of each of 4 cooperating institutions (in Perm, Kiel, Koeln, Duesseldorf) has been equipped with the special software Mikroskopkonferenz. Additional videocameras allow the transmission of the cooperators to each other. Headsets are used to avoid reecho. As a prerequisite an internet connection with a 54 KBits capacity has to be provided. RESULTS: Between January and December 2009, 26 children (median age 2; 5 years, 12 females and 14 males) with suspected or proven malignant solid tumors have been discussed in 11 telemicroscopic conferences by international cooperators. CONCLUSION: This cooperation demonstrates the proof of principle to obtain second opinions in short time over far distances for seldom diseases on a scientific level. Sands, D. Z. (2008). "ePatients: engaging patients in their own care." Medscape journal of medicine 10(1): 19. Patients want information, ideally tailored to their needs. They want to discuss this with their physicians without being shooed away, and would appreciate getting pointers. They even want access to their test results and medical records. Sapirstein, A., N. Lone, et al. (2009). "Tele ICU: paradox or panacea?" Best Practice & Research. Clinical Anaesthesiology 23(1): 115-126. Telemedicine has been studied in the intensive care unit for several decades, but many questions remain unanswered regarding the costs and the benefits of its application. Telemedicine ICU (Tele-ICU) is an electronic means to link physical ICUs to another location which assists in medical decision making. Given the shortage of intensive care physicians in the US, Tele-ICU systems could be an efficient mechanism for physicians to manage a larger number of critical care

patients. This chapter will examine the current state of telemedicine in an age of rapidly expanding medical information technology and increasing demand for intensive care services. While we believe that the future of Tele-ICU is promising, there are multiple issues that must be addressed to increase the benefit of TeleICU. Tele-ICU is expensive to deploy and use, it may add burdens to existing intensivists, and it requires organizational and culture changes that can be difficult to accomplish. [References: 57] Scalvini, S., C. Tridico, et al. (2009). "The SUMMA Project: a feasibility study on telemedicine in selected Italian areas." Telemedicine Journal & E-Health 15(3): 261269. Telemedicine is achieving relevant clinical importance in rural areas in the management of patients. The Second opinion Unificata per Medici di Medicina generAle (SUMMA) Project was designed to evaluate the feasibility of a joint telemedicine service application across general practitioners and clinical specialists in Italy. The secondary objective of the study included the comparison of telemedicine with the routine general practitioners' approach and a costeffectiveness evaluation. One hundred and thirty-five general practitioners from Lombardy, Molise, and Valle d'Aosta were enrolled. An ad hoc questionnaire was used to evaluate the feasibility, approval, efficacy, and satisfaction of telemedicine among the general practitioners. Ninety-three general practitioners used the telemedicine consultation (responders) for a total of 1,396 calls (1,264 for cardiology, 65 for dermatology, 32 for diabetology, 22 for rheumatology, and 13 for pneumology). In cardiology, telemedicine was used to address all problems without further action in 733 cases (61%). Ninety-eight percent of responders indicate satisfaction with telemedicine. The cost of telemedicine in our study was estimated to be 25.36 Euros/contact. In conclusion, the SUMMA Project demonstrated for the first time clinically the effectiveness of secondopinion consultation by general practitioners and therefore fulfilling the actual needs in areas usually managed by the National Health System. Scrogham, R. (2009). "Video Conferencing Essentials: Telehealth Technology An Executive Summary." this was an overview of videoconferencing and the simple implementation document. Seto, E., K. J. Leonard, et al. (2010). "Attitudes of heart failure patients and health care providers towards mobile phone-based remote monitoring." Journal of Medical Internet Research 12(4): e55. BACKGROUND: Mobile phone-based remote patient monitoring systems have been proposed for heart failure management because they are relatively inexpensive and enable patients to be monitored anywhere. However, little is known about whether patients and their health care providers are willing and able to use this technology. OBJECTIVE: The objective of our study was to assess the attitudes of heart failure patients and their health care providers from a heart function clinic in a large urban teaching hospital toward the use of mobile phone-

based remote monitoring. METHODS: A questionnaire regarding attitudes toward home monitoring and technology was administered to 100 heart failure patients (94/100 returned a completed questionnaire). Semi-structured interviews were also conducted with 20 heart failure patients and 16 clinicians to determine the perceived benefits and barriers to using mobile phone-based remote monitoring, as well as their willingness and ability to use the technology. RESULTS: The survey results indicated that the patients were very comfortable using mobile phones (mean rating 4.5, SD 0.6, on a five-point Likert scale), even more so than with using computers (mean 4.1, SD 1.1). The difference in comfort level between mobile phones and computers was statistically significant (P< .001). Patients were also confident in using mobile phones to view health information (mean 4.4, SD 0.9). Patients and clinicians were willing to use the system as long as several conditions were met, including providing a system that was easy to use with clear tangible benefits, maintaining good patient-provider communication, and not increasing clinical workload. Clinicians cited several barriers to implementation of such a system, including lack of remuneration for telephone interactions with patients and medicolegal implications. CONCLUSIONS: Patients and clinicians want to use mobile phone-based remote monitoring and believe that they would be able to use the technology. However, they have several reservations, such as potential increased clinical workload, medicolegal issues, and difficulty of use for some patients due to lack of visual acuity or manual dexterity. Shaikh, N., C. U. Lehmann, et al. (2008). "Efficacy and feasibility of teledermatology for paediatric medical education." Journal of Telemedicine & Telecare 14(4): 204-207. We evaluated a teledermatology consultation service in the education of medical trainees. The selection of cases for consultation was at the discretion of the trainees, who could contact the study team for advice about obtaining photographs and submitting the case to a web-based system. Asynchronous structured feedback was provided to trainees by an academic paediatric dermatology consultant using a web-based interface. Efficacy was evaluated by examining the trainees' self-reported competency in clinical dermatology skills before and after teleconsultation. A total of 44 trainees (31 residents and 13 medical students) completed 50 consultations. Trainees reported significant improvement (mean improvement 22%, P < 0.002) in competency in five of the six areas assessed. In addition, 88% of trainees were very satisfied with the teaching methodology (> or =5 on a 7-point scale) and 86% were very likely to apply the information in their future practice (> or =5 on a 7-point scale). We believe that teledermatology has great potential in the education of medical trainees. Shannon, G., T. Nesbitt, et al. (2002). "Telemedicine/telehealth: an international perspective. Organizational models of telemedicine and regional telemedicine networks." Telemedicine Journal & E-Health 8(1): 61-70. paper looked at the organization of telemedicine programs. they show four models of delivery and what makes them successful

Sheehan, F. H., M. A. Ricci, et al. (2010). "Expert visual guidance of ultrasound for telemedicine." Journal of Telemedicine & Telecare 16(2): 77-82. Expert visual guidance (EVG) is computer assistance that displays to the examiner how the image plane moves towards (or away from) a desired anatomical location as the ultrasound probe is manipulated over the patient's body. We tested whether EVG by a remote expert could assist inexperienced examiners in acquiring abdominal ultrasound images. The inexperienced examiners were 20 medical students, who were randomly assigned to verbal instruction alone (Group 1) or to EVG (Group 2). The examiners were tested on their ability to visualize the abdominal aorta and the right kidney. Group 2 was more successful in identifying specified anatomy in longitudinal and crosssectional views of the aorta (95 vs. 75%, P = 0.032) and kidney (98 vs. 88%, P = 0.09). The groups succeeded equally well in obtaining a true cross-sectional view of the aorta. Kidney length was also similar when measured by the two groups. The results demonstrate that an inexperienced ultrasonographer can be significantly assisted by EVG compared to verbal instruction alone. This could be useful for tele-mentoring in rural hospitals as well as for teaching, both in person and at a remote site. Shepherd, L., D. Goldstein, et al. (2008). "Enhancing psychosocial care for people with cancer in rural communities: what can remote counselling offer?" Australian Health Review 32(3): 423-438. Rural cancer patients are often disadvantaged in access to psychological services. We reviewed remote counselling research for psychological support using telephone, videoconferencing, and the Internet as a potential solution. Telephone counselling is the most extensively researched, while there are encouraging findings in emerging research about videoconferencing and Internet-based psychological care. Where no face-to-face psychological service exists, these technologies are promising, yet unproven. Less variable methods are needed to better assess the technology and therapeutic approach for stronger evidence. [References: 106] Shivji, S., P. Metcalfe, et al. (2011). "Pediatric surgery telehealth: patient and clinician satisfaction." Pediatric Surgery International 27(5): 523-526. PURPOSE: The Stollery Children's Hospital serves a very large geographic region of over at least 650,000 km2 with patients from outside of Edmonton accounting for approximately 50% of the service population. The aim of this study is to document the experience and opinion of the patient and clinician satisfaction with telehealth encounter for various pediatric surgical consultations and followup as a way to bridge the distance gap. METHODS: We observe our experience with recent telehealth implementation from 2008 to 2009. Qualitative data were collected through questionnaires aimed at patients and clinicians. RESULTS: There were 259 pediatric surgical telehealth encounters, of which 37% were from outside the province. There were 42 antenatal multidisciplinary, 13 chronic pain, 103 general surgery, 2 orthopedic, 63 urology, 33 head and shape nurse

practioner clinic, and 3 neurosurgery consults. 83 patient and 12 clinician questionnaires were completed. 97% of patients and 73% of clinicians reported satisfaction with having a telehealth session. 97% of the patients reside more than 200 km from the city and 77% live more than 400 km away. 48% reported a cost saving >$500-$700. CONCLUSION: Telehealth for pediatric surgical services is an alternative as an acceptable, effective, and appropriate way to consult and follow-up pediatric patients who live in significantly remote areas with great clinician and patient satisfaction. Shore, J. H., J. D. Bloom, et al. (2008). "Telepsychiatry with rural American Indians: issues in civil commitments." Behavioral Sciences & the Law 26(3): 287-300. The use of live interactive videoconferencing to provide psychiatric care, telepsychiatry, has particular relevance for improving mental health treatment to rural American Indian reservations. There is little literature on civil commitments in telepsychiatry and none specifically addressing this topic among American Indians. This article reviews telepsychiatry in the mental health care of American Indians, civil commitments and telepsychiatry in general, and the current state of civil commitments in American Indian communities. We conclude by considering commitment through telepsychiatry in rural reservations and offering guidelines to assist practitioners in navigating this challenging landscape. Civil commitments of American Indian patients residing in rural reservations can be successfully accomplished through videoconferencing by thoughtful and informed clinicians. However, much more work is needed in this area, including research into the cultural attitudes and perspectives towards commitments and further inquiry regarding potential legal precedents, as well as case reports and examples of this work. (c) 2008 John Wiley & Sons, Ltd. [References: 45] Slodkowska, J., J. Pankowski, et al. (2009). "Use of the virtual slide and the dynamic real-time telepathology systems for a consultation and the frozen section intra-operative diagnosis in thoracic/pulmonary pathology." Folia Histochemica et Cytobiologica 47(4): 679-684. We report the results of a study designed for assessment of the diagnostic accuracy and usability of internet-based digital microscopy: the dynamic real-time telepathology system (Coolscope) and the Virtual microscopy (Aperio Scan Scope) system, in the context of pulmonary pathology. The systems were implemented to the routine pulmonary pathology workflows and used for the intra-operative frozen-section primary diagnosis as well as for the secondary (consultative) diagnosis. The histological material presented for the teleconsultations included the samples of lung parenchyma, bronchial biopsy and resected lung/bronchi tumours. For the primary diagnosis 4 categories of material can be distinguished (304 samples): 1) the frozen sections of lung tumours, resected bronchial margins and lymph nodes; 2) fine needle aspiration [FNA] biopsies (TBNA; EBUS-TBNA, EUS-FNA; 3) oligobiopsies of bronchus, oesophagus, skin; and 4) exfoliative cytology. The telepathology diagnoses compared with conventional light microscopy diagnoses showed very high concordance for the Coolscope and Aperio Virtual Slide modality: 87.5% and

100%, respectively - within the group of teleconsultations. For the frozen sections, the primary telediagnoses were concordant with the light microscopy paraffin sections diagnoses in 100% for Aperio; and in 97.5% for Coolscope. An excellent agreement (100%) was seen in the telediagnoses and conventional slides diagnoses for FNA, oligobiopsies and cytology - for both telepathology systems. These results provide some encouragement for the implementation of Coolscope and virtual slide-based telepathology (Aperio) system to the routine histopathological diagnostics. Smith, A. C. and L. C. Gray (2009). "Telemedicine across the ages." Medical Journal of Australia 190(1): 15-19. Telemedicine can help improve access to health care for people in rural and remote communities, but its uptake has been slow and fragmented. A telepaediatric service in Queensland, initiated in 2000, has made use of mobile "robot" videoconferencing systems. It has been cost-effective and well accepted by patients and clinicians. Telegeriatric services were instigated in Queensland in 2005, principally using videoconferencing. Telegeriatrics has been ideal for frail older patients in remote areas. For telemedicine to become a mainstream service, its focus must move beyond simply the provision of equipment and network connectivity. Telemedicine must be funded adequately if it is to be successful. Speedie, S. M., A. S. Ferguson, et al. (2008). "Telehealth: the promise of new care delivery models." Telemedicine Journal & E-Health 14(9): 964-967. Telehealth possesses a significant potential to revolutionize healthcare delivery processes by challenging some of the long-held assumptions about healthcare delivery and by creating innovative alternative models. Those assumptions relate to the location-linked nature of healthcare and its episodic nature. Telehealth can challenge the assumption that healthcare is inextricably linked to the provider's location. Numerous models involving such approaches as interactive videoconferencing and store-and-forward technologies already exist. Telehealth also challenges the episodic nature of care. One example is provided by the models evolving from the convergence of three technologies: remote monitoring, electronic health records, and clinical decision support systems. Telehealthbased models of care can also lead to a reduced demand for services and greater efficiencies in the care process. These telehealth-enabled care delivery models have the potential to reduce the costs of care, improve quality, and mitigate provider shortages. However, the achievement of these goals is not straightforward. The current healthcare financing system is not designed to support such new models, and the existing healthcare culture is deeply ingrained within workflow processes and provider attitudes. A great deal of work remains to be done before the benefits of telehealth-based care delivery models are fully realized. Change is inherently risky but we must have the courage to assume the risk in order to create telehealth-driven innovations that lead to better and more cost-effective medical care for all.

Staff, H. I. N. (2011). "7 percent of U.S. docs video chat with patients." Health IT News. a study undertaken by a marketing firm survey physicians and found that 7% of physicians in the US already provide patient care using teleconferencing. the survey found that oncologists and psychiatrists are more likely to use the technology. Styles, V. (2008). "Service users' acceptability of videoconferencing as a form of service delivery." Journal of Telemedicine & Telecare 14(8): 415-420. We conducted a study of videoconferencing for delivering an Augmentative and Alternative Communication (AAC) service. AAC is a clinical field that attempts to compensate for the impairment and disability of people with severe expressive communication disorders. A total of 12 participant groups trialled initial AAC assessments via videoconference at a bandwidth of 768 kbit/s. The participant groups consisted of the client, the assessing speech and language therapist, and those who accompanied them to the session (usually their local speech and language therapist and any relatives or carers). Six of these groups progressed to receive review appointments. Following each of the sessions, all of the participants completed a questionnaire. Participants indicated an 88% satisfaction with the videoconference assessment session and a 95% satisfaction with review videoconference sessions. Clients provided the most positive feedback in their questionnaires, while the speech and language therapists were the most critical of the process. The findings suggest that an AAC service can be delivered effectively by videoconference. Sullivan, D. H., M. Chapman, et al. (2008). "Videoconferencing and forensic mental health in Australia." Behavioral Sciences & the Law 26(3): 323-331. Videoconferencing is in common use in Australian forensic mental health services. It provides opportunities to link remote prisons, courts, and psychiatric clinics with distant specialist services, and enables a range of activities including assessment, treatment and feedback, expert testimony, education, and interservice planning. These functions are acceptable to patients and clinicians, and in Australia videoconferencing minimizes disruption to small services and their patients, who might otherwise face lengthy journeys. In particular, marginalized patient groups, including indigenous people and prisoners, may receive better services. The evidence base supports use of videoconferencing despite a number of practical, legal, and clinical issues that may reduce its effectiveness compared with face-to-face assessments. Videoconferencing technologies are critical to effective forensic mental health services in Australia. (c) 2008 John Wiley & Sons, Ltd. Suzuki, K., Y. Hirasawa, et al. (2009). "A web-based remote radiation treatment planning system using the remote desktop function of a computer operating system: a preliminary report." Journal of Telemedicine & Telecare 15(8): 414-418. We developed a web-based, remote radiation treatment planning system which allowed staff at an affiliated hospital to obtain support from a fully staffed central institution. Network security was based on a firewall and a virtual private network

(VPN). Client computers were installed at a cancer centre, at a university hospital and at a staff home. We remotely operated the treatment planning computer using the Remote Desktop function built in to the Windows operating system. Except for the initial setup of the VPN router, no special knowledge was needed to operate the remote radiation treatment planning system. There was a time lag that seemed to depend on the volume of data traffic on the Internet, but it did not affect smooth operation. The initial cost and running cost of the system were reasonable. Takeuchi, R., H. Harada, et al. (2008). "Field testing of a remote controlled robotic teleecho system in an ambulance using broadband mobile communication technology." Journal of Medical Systems 32(3): 235-242. We report the testing of a mobile Robotic Tele-echo system that was placed in an ambulance and successfully transmitted clear real time echo imaging of a patient's abdomen to the destination hospital from where this device was being remotely operated. Two-way communication between the paramedics in this vehicle and a doctor standing by at the hospital was undertaken. The robot was equipped with an ultrasound probe which was remotely controlled by the clinician at the hospital and ultrasound images of the patient were transmitted wirelessly. The quality of the ultrasound images that were transmitted over the public mobile telephone networks and those transmitted over the Multimedia Wireless Access Network (a private networks) were compared. The transmission rate over the public networks and the private networks was approximately 256 Kbps, 3 Mbps respectively. Our results indicate that ultrasound images of far higher definition could be obtained through the private networks. Tamariz, F., R. Merrell, et al. (2009). "Design and implementation of a web-based system for intraoperative consultation." World Journal of Surgery 33(3): 448-454. BACKGROUND: With the use of electronic information distribution and telecommunication technologies, surgical teleconsultation is possible as a vehicle for consulting with experts remotely without their physical presence in the operating room (OR). This study evaluated real-time teleconsultation from the OR to remote consultants in the Russian Research Center of Surgery, Moscow, Russia and the Fundeni Clinical Hospital, Bucharest, Romania. METHODS: We evaluated the effectiveness of teleconsultation using a secure website interface where consultants could navigate through multimedia-based electronic documentation of a surgical procedure and identify the anatomic landmarks underlying the need for consultation. Additionally, management of a remote camera view by consultants was evaluated. RESULTS: Fifteen thyroidectomies and parathyroidectomies were studied to confirm by teleconsultation the identity of 22 recurrent laryngeal nerves (RLNs). There was no Internet connectivity interruption or dropped signal, and the bandwidth was consistently greater than 1 Mbps. Consultants spent an average of 6 min to review an average of 35 min of surgical records to identify the 22 RLNs. CONCLUSIONS: This study validated a system for real-time teleconsultation using web-based surgical records. In addition, the ability of the consultant to manage the camera view remotely

without interrupting the surgical procedure was confirmed. Tan, E., A. Oakley, et al. (2010). "Interobserver variability of teledermoscopy: an international study." British Journal of Dermatology 163(6): 1276-1281. BACKGROUND: Teledermoscopy is a rapidly developing field of dermatology with studies demonstrating excellent agreement with face-to-face diagnosis. However, we are unaware of studies evaluating interobserver variability in diagnosis between dermatologists from different continents. This evaluation is important to determine the robustness of teledermoscopy and allow comparisons to be made between different studies. OBJECTIVES: To assess the interobserver diagnostic variability between five independent experienced dermatologists (A-E) in New Zealand, Australia and the U.S.A. METHODS: Images from 979 lesions from 206 patients were distributed to five dermatologists. The lesions were viewed and diagnoses recorded using MoleMap Diagnose (MoleMap, Auckland, New Zealand) software. The diagnoses were analysed for interobserver variability. RESULTS: There was excellent agreement between four of five dermatologists (A-D) for lesions that were agreed upon as melanoma (kappa = 0.81-0.97) and benign naevus (kappa = 0.770.82).The fifth dermatologist (E) made a more frequent diagnosis of atypical naevus and melanoma than the others. For nonmelanocytic lesions, there was moderate to very good agreement for seborrhoeic keratosis (kappa = 0.64-0.80) and basal cell carcinoma (kappa = 0.55-0.67), but poor agreement for invasive squamous cell carcinoma (SCC) (kappa = 0.05-0.15). Agreement for actinic keratosis (kappa = 0.32-0.67) and SCC in situ (kappa = 0.15-0.32) was only moderate. When atypical and benign naevi were grouped together and actinic keratosis and SCC in situ grouped together, there was better agreement among all dermatologists. There was good ability to distinguish malignant from benign lesions (kappa = 0.57-0.93). CONCLUSIONS: There was good agreement among dermatologists A-D but dermatologist E varied from the group with more frequent diagnosis of melanoma and atypical naevus. This difference could be due to different definition of terms with lack of consensus guidelines in definition of atypical naevus, lack of familiarity with the specific patient population and/or diagnostic drift. Copyright 2010 The Authors. BJD Copyright 2010 British Association of Dermatologists. Taylor, D. M., J. I. Cameron, et al. (2009). "Exploring the feasibility of videoconference delivery of a self-management program to rural participants with stroke." Telemedicine Journal & E-Health 15(7): 646-654. Moving On after STroke (MOST(R)) is a multimodal, psycho-educational, and exercise self-management program for people with stroke and their caregivers. The objective of this study was to explore the feasibility of videoconference delivery to rural communities. Seven participants, their caregivers, and two facilitators formed one group, located in an urban center. Five participants and their caregivers from two remote locations were connected by videoconference. Feasibility was assessed by examining recruitment and attendance rates; program adaptations; and participant, facilitator, and staff perceptions. Data

sources included logs, surveys, focus groups, and interviews. To examine preliminary outcomes, goal attainment, balance, mood, participation, and walking endurance were measured pre-, post-, and 3 months following intervention. Twelve participants were recruited in 3 weeks. Attendance rates were 89.8% for the local group and 70.4% for the remote group. Program adaptations, facilitation strategies, and involvement of onsite support promoted the success of the videoconference delivery. Participants reported that the program provided people with stroke as well as caregivers with greater awareness of stroke, increased social support, and improved ability to cope. They reported a decrease in loneliness by sharing with others in a similar situation, even if they were in a different community. Pre-post improvements were seen in goal setting, mood, balance, balance confidence, and walking endurance. Videoconferencing is a feasible method for the dissemination of the MOST program to rural areas. This form of delivery is associated with improvements in goal achievement, mood, balance, and endurance, and is well received by all participants. Taylor, J., J. Edwards, et al. (2009). "Improving transfer of mental health care for rural and remote consumers in South Australia." Health & Social Care in the Community 17(2): 216-224. In Australia, it is commonplace for tertiary mental health care to be provided in large regional centres or metropolitan cities. Rural and remote consumers must be transferred long distances, and this inevitably results in difficulties with the integration of their care between primary and tertiary settings. Because of the need to address these issues, and improve the transfer process, a research project was commissioned by a national government department to be conducted in South Australia. The aim of the project was to document the experiences of mental health consumers travelling from the country to the city for acute care and to make policy recommendations to improve transitions of care. Six purposively sampled case studies were conducted collecting data through semistructured interviews with consumers, country professional and occupational groups and tertiary providers. Data were analysed to produce themes for consumers, and country and tertiary mental healthcare providers. The study found that consumers saw transfer to the city for mental health care as beneficial in spite of the challenges of being transferred over long distances, while being very unwell, and of being separated from family and friends. Country care providers noted that the disjointed nature of the mental health system caused problems with key aspects of transfer of care including transport and information flow, and achieving integration between the primary and tertiary settings. Improving transfer of care involves overcoming the systemic barriers to integration and moving to a primary care-led model of care. The distance consultation and liaison model provided by the Rural and Remote Mental Health Services, the major tertiary provider of services for country consumers, uses a primary care-led approach and was highly regarded by research participants. Extending the use of this model to other primary mental healthcare providers and tertiary facilities will improve transfer of care.

Temple, V., C. Drummond, et al. (2010). "A comparison of intellectual assessments over video conferencing and in-person for individuals with ID: preliminary data." Journal of Intellectual Disability Research 54(6): 573-577. BACKGROUND: Video conferencing (VC) technology has great potential to increase accessibility to healthcare services for those living in rural or underserved communities. Previous studies have had some success in validating a small number of psychological tests for VC administration; however, VC has not been investigated for use with persons with intellectual disabilities (ID). A comparison of test results for two well known and widely used assessment instruments was undertaken to establish if scores for VC administration would differ significantly from in-person assessments. METHOD: Nineteen individuals with ID aged 23-63 were assessed once in-person and once over VC using the Wechsler Abbreviated Scale of Intelligence (WASI) and the Beery-Buktenica Test of Visual-Motor Integration (VMI). RESULTS: Highly similar results were found for test scores. Full-scale IQ on the WASI and standard scores for the VMI were found to be very stable across the two administration conditions, with a mean difference of less than one IQ point/standard score. CONCLUSION: Video conferencing administration does not appear to alter test results significantly for overall score on a brief intelligence test or a test of visual-motor integration. Thara, R., S. John, et al. (2008). "Telepsychiatry in Chennai, India: the SCARF experience." Behavioral Sciences & the Law 26(3): 315-322. India, with its huge population and limited mental health resources, must find alternative ways of delivering its mental healthcare services. Telepsychiatry seems to be a promising option even with no regulatory authority in place or specific laws in India that deal with telemedicine practice, there has been a mushrooming of telemedicine services in India. Healthy cooperation between government organizations such as the Indian Space Research Organization (ISRO) and institutions in the non-government and private sectors is another key feature in India. The experience of the Schizophrenia Research Foundation (SCARF), at Chennai, in South India, in running and establishing a telepsychiatry network is presented in this article. We identified the following tasks as essential to ensure an efficient intervention using telemedicine: identifying a suitable technology, a suitable location, and a local collaborator; providing training and creating awareness; establishing peripheral telepsychiatry centers and ensuring case documentation; and accountability. (c) 2008 John Wiley & Sons, Ltd. Theuns, D. A. M. J., M. Rivero-Ayerza, et al. (2009). "Analysis of 57,148 transmissions by remote monitoring of implantable cardioverter defibrillators." Pacing & Clinical Electrophysiology 32 Suppl 1: S63-65. INTRODUCTION: Remote monitoring of implantable cardioverter defibrillators (ICD) is designed to decrease the number of ambulatory visits and facilitate the early detection of adverse events. We examined the impact of remote monitoring on clinical workload by a comprehensive analysis of transmitted events. METHODS: The study population consisted of 146 recipients of ICD capable of remote monitoring. Data were transmitted daily or in case of pre-specified events

(e.g., arrhythmia, out-of-range lead and/or shock impedance). Transmitted events were classified as clinical (disease-related) or system-related. Event rates/patient/month were calculated and compared according to events classification and clinical groups. RESULTS: During a mean follow-up of 22 +/16 months, a total of 57,148 remote transmissions were recorded. Of these transmissions, 1009 (1.8%) were triggered by a pre-specified event, including induced ventricular fibrillation (VF) episodes during defibrillation threshold testing. The median number of events/patient/month was 0.14. Event rates were similar in patients with primary and secondary prevention indications for ICD (0.15 vs. 0.11). After exclusion of the induced VF episodes, 5.6% of transmitted events were classified as system-related and 94.4% as clinical. The median number of clinical events/patient/month was 0.023. The clinical event-free rates were 62% and 45%, at 1 and 4 years, respectively. CONCLUSION: Remote monitoring of ICD patients is feasible. Despite the large number of data transmissions, remote monitoring imposed a minimal additional burden on the clinical workload. The rate of triggered data transmissions by critical events was, relatively, very low. Thielscher, C. and C. R. Doarn (2008). "Long-term future of telemedicine in Germany: the patient's, physician's, and payer's perspective." Telemedicine Journal & E-Health 14(7): 701-706. While the near-term future of telemedicine development in Germany is quite clear, the long-term future has not been investigated. To determine telemedicine's long-term future in Germany, in-depth interviews were conducted with 20 key decision-makers in the German healthcare system. Interviewees included payers, doctors and their professional associations; and patients and their organizations. These individuals were asked what their expectations were in the application of telemedicine. According to the interviewees, several changes in the healthcare system as a whole will occur, which influence telemedicine. These include increase in cost pressure; the changing role of the payers and companies--as opposed to public organizations--playing a more active role in managing care. Physicians foresee more changes than payers do. Patients expect telemedicine to strengthen their role as patients. Most important telemedicine applications will be the "Gesundheitskarte" (a smart card enabling access to patient records), telemedicine as an enabling technology for other provider integration models, information systems for patients, and telemonitoring. The future looks promising for telemedicine in Germany. Thielst, C. B. (2010). "At the crossroads: NRTRC white paper examines trends driving the convergence of telehealth, EHRs and HIE." World Hospitals & Health Services 46(4): 17-23. From the American Recovery and Reinvestment Act (ARRA) and the newly passed healthcare reform legislation to emerging reimbursement models and shifting consumer health trends, a confluence of events are driving radical change in the nation's healthcare system and bringing about the convergence of telehealth, electronic health records (EHRs) and health information exchange (HIE). That is the focus of "The Crossroads of Telehealth, Electronic Health

Records & Health Information Exchange: Planning for Rural Communities," a new white paper from the Northwest Regional Telehealth Resource Center (NRTRC). "Accelerating adoption and utilization of telehealth technologies, telemedicine in particular, will be critical to a successful stakeholder response to the disruptive changes that are underway in healthcare," said NRTRC Executive Director Christina B. Thielst, FACHE. "By leveraging telehealth networks and their existing infrastructures, Regional Extension Centers, HIEs and other datasharing initiatives will be better-positioned to fulfill their commitments to the healthcare delivery system of the future--a system in which even the most rural and remote populations have timely access to care and their health records." The white paper explores emerging trends and recent disruptors impacting the healthcare delivery system and examines the opportunities they present for the advancement of telecommunications-based health solutions and the broadband infrastructure available through telehealth networks. It also takes an in-depth look at the various uses of telehealth and the most common delivery models of telemedicine, as well as the role of the telehealth network and Telehealth Resource Centers (TRCs) in expanding the reach of these vital initiatives. Finally, the white paper highlights the evolution of the REACH Montana Telehealth Network from facilitating teleradiology at three remote sites into a consortium of healthcare providers at 18 sites linked by high-bandwidth telecommunications in the north central region of Montana. REACH, which considers HIE to be a primary function, is currently working to leverage its existing T1 infrastructure to create the "railroad tracks" that will carry medical data and information within the region and beyond. "This white paper is an excellent analysis of the intersection of telehealth and health information technology, and the opportunities and challenges this electronic technology will bring to rural America," said Terry J. Hill, Executive Director of the Rural Health Resource Center, the Duluth, Minn.based national knowledge center for rural hospitals providing technical assistance, information, education and other resources to rural health care providers and their communities. Adds Thielst: "Crossroads is a valuable planning tool for any healthcare stakeholder, but it is especially important for rural communities wanting to address health information exchange. It is just one of many resources available through the NRTRC to help advance the involvement of teleheatlh networks in HIE initiatives and to help transform the telehealth infrastructure into the 'superhighway' across which remote and rural areas will finally be able to participate in the widespread exchange of electronic health information." One of five TRCs in the nation, the NRTRC leverages the collective expertise of 33 telehealth networks across Alaska, Hawaii, Idaho, Montana, Oregon, Utah, Washington, Wyoming, and United States-affiliated Pacific Islands to share information and resources which assist in the development of new telehealth programs. The NRTRC is focused on further growth and new provider adoption of telehealth technologies to enhance delivery systems and reduce organizational and patient costs. Thompson, D. A., R. Leimig, et al. (2009). "Assessment of depressive symptoms during post-transplant follow-up care performed via telehealth." Telemedicine Journal & E-

Health 15(7): 700-706. Telehealth provides a successful medium for the treatment of depression and other mental health illnesses. Often, inadequate treatment for this condition is found in patients with chronic co-morbid conditions such as those presented by the transplant recipient, a population at risk for depression. One concern of healthcare providers is the inability to adequately screen for symptoms of depression. This secondary analysis describes depression screening of 138 transplant recipients receiving follow-up care via telehealth (TH) and standard care (SC) as part of a larger National Institute of Nursing Research-funded randomized clinical trial. Of subjects who consented, 70 (51%) were randomized to the TH portion of the study. Depressive symptoms were measured by the Center for Epidemiologic Studies-Depression (CES-D) survey at study entry and at 6 and 12 months postconsent into the study. Univariate and subgroup analyses using SAS found no differences between the TH (n = 70) and SC (n = 68) group for demographic and social characteristics. No differences in CES-D scores were found between TH and SC groups. The concern in adding distance in the care of this medically fragile population was not substantiated in this study. Torres-Pereira, C., R. S. Possebon, et al. (2008). "Email for distance diagnosis of oral diseases: a preliminary study of teledentistry." Journal of Telemedicine & Telecare 14(8): 435-438. We examined the feasibility of distance diagnosis of oral diseases, using transmission of digital images by email. Twenty-five cases of oral lesions were documented during a 12-month study in a primary care public health clinic in Parana in Southern Brazil. Clinical electronic charts and images were produced and sent by email to two oral medicine specialists with a median of 10 years experience in the field. The consultants provided a maximum of two clinical hypotheses for each case. In 15 of the 25 cases (60%) both consultants made a correct diagnosis; in seven cases (28%) only one consultant made a correct diagnosis; and in three cases (12%) neither consultant made a correct diagnosis. Thus in 88% of cases, at least one consultant was able to provide the correct diagnosis. The results suggest that distant diagnosis can be an effective alternative in the diagnosis of oral lesions and that the using two distant consultants improves diagnostic accuracy. Primary care public health clinics may benefit from the use of email and digital cameras for telehealth in remote areas where oral medicine specialists are not available. Trankler, U., O. Hagen, et al. (2008). "Video quality of 3G videophones for telephone cardiopulmonary resuscitation." Journal of Telemedicine & Telecare 14(7): 396-400. We simulated a cardiopulmonary resuscitation (CPR) scene with a manikin and used two 3G videophones on the caller's side to transmit video to a laptop PC. Five observers (two doctors with experience in emergency medicine and three paramedics) evaluated the video. They judged whether the manikin was breathing and whether they would give advice for CPR; they also graded the confidence of their decision-making. Breathing was only visible from certain orientations of the videophones, at distances below 150 cm with good

illumination and a still background. Since the phones produced a degradation in colours and shadows, detection of breathing mainly depended on moving contours. Low camera positioning produced better results than having the camera high up. Darkness, shaking of the camera and a moving background made detection of breathing almost impossible. The video from the two 3G videophones that were tested was of sufficient quality for telephone CPR provided that camera orientation, distance, illumination and background were carefully chosen. Thus it seems possible to use 3G videophones for emergency calls involving CPR. However, further studies on the required video quality in different scenarios are necessary. Tsai, C.-L., B. Madore, et al. (2008). "Automated retinal image analysis over the internet." IEEE Transactions on Information Technology in Biomedicine 12(4): 480-487. Retinal clinicians and researchers make extensive use of images, and the current emphasis is on digital imaging of the retinal fundus. The goal of this paper is to introduce a system, known as retinal image vessel extraction and registration system, which provides the community of retinal clinicians, researchers, and study directors an integrated suite of advanced digital retinal image analysis tools over the Internet. The capabilities include vasculature tracing and morphometry, joint (simultaneous) montaging of multiple retinal fields, cross-modality registration (color/red-free fundus photographs and fluorescein angiograms), and generation of flicker animations for visualization of changes from longitudinal image sequences. Each capability has been carefully validated in our previous research work. The integrated Internet-based system can enable significant advances in retina-related clinical diagnosis, visualization of the complete fundus at full resolution from multiple low-angle views, analysis of longitudinal changes, research on the retinal vasculature, and objective, quantitative computer-assisted scoring of clinical trials imagery. It could pave the way for future screening services from optometry facilities. Umefjord, G., H. Sandstrom, et al. (2008). "Medical text-based consultations on the Internet: a 4-year study." International Journal of Medical Informatics 77(2): 114-121. BACKGROUND: The Internet is increasingly used for health matters including Ask the doctor services. AIM: To describe users and usage pattern of text-based medical consultation with family physicians on the Internet. METHODS: Descriptive analysis of the first 4 years' use of a Swedish Ask the doctor service concerning number of inquiries, age and gender of inquirers. Time of day and week, types of medical inquiries, and use in relation to population density was analyzed during the last year of the study. RESULTS: We found a considerable number of users, with 38,217 inquiries submitted to the service. Three-fourths of the inquirers were women, thus exceeding the gender difference seen in regular health care. The typical user was a woman aged 21-60 years. The service was used any time day or night, 7 days a week. Almost half of the inquiries were submitted during evenings and nights. Most areas of medicine were represented in the inquiries, reflecting the fact that there was no control of what an inquiry should include. The use was widespread over the country but more frequent per

capita in more densely populated areas as defined by postal code. CONCLUSION: In the study of a service for text-based consultations with family physicians on the Internet, we found a geographically widely distributed use, slowly but gradually increasing during a 4-year period. The use increased more rapidly among young and middle-aged women. Asynchronous text-based consultation is likely to expand in the near future. Valente, A., D. Pereira, et al. (2010). "Vital signs remote monitoring through multipoint videoconferencing." Conference Proceedings: ... Annual International Conference of the IEEE Engineering in Medicine & Biology Society 2010: 2176-2179. A system for remote monitoring of patients' vital signs using multipoint videoconferencing is proposed. A multiparametric module and a videoconference server were developed to set up a proof-of-concept where a text was streamed live as data was captured, while a third party monitored it. van der Heijden, J. P., N. F. de Keizer, et al. (2010). "A pilot study on tertiary teledermatology: feasibility and acceptance of telecommunication among dermatologists." Journal of Telemedicine & Telecare 16(8): 447-453. Tertiary teledermatology (TTD), where a general dermatologist consults a specialized dermatologist on difficult cases, is a relatively new telemedicine service. We evaluated TTD in a Dutch university hospital, where 13 general dermatologists used TTD to consult 11 specialized dermatologists and two residents at the university medical centre. We measured the avoided referrals to the university centre, the usability of the system and the user acceptance of it. During a three-month study, general dermatologists consulted via TTD 28 times. In 17 of the consultations (61%), the general dermatologists would have referred their patients to the university centre if teledermatology had not been available. Referral was not necessary after teledermatology for 12 of these 17 consultations (71%). The mean usability score (0-100) of all the users was 80. All dermatologists were satisfied with TTD (mean satisfaction of 7.6 on a 10-point scale) and acceptance was high. The baseline measurements showed that half of tertiary referrals were suitable for TTD. These results suggest that TTD reduces unnecessary physical referrals and that users are satisfied with it. A large-scale evaluation is now required. Van Offenbeek, M. A. G. and A. Boonstra (2010). "Does telehomeconsultation lead to substitution of home visits? Analysis and implications of a telehomecare program." Studies in Health Technology & Informatics 157: 148-153. This study's objective was to determine and to explain the potential substitution effects of a nurse-led video teleconsultation service for homecare clients. To that end the largest program in the Netherlands up till 2009 was analyzed. This program's aim was to realize partly substitution of homecare visits by telecare for carefully selected clients. The study was multi-method. Each video contact was registered, and a sample was described on forms during an 8- month period starting half a year after implementation. (Changes in) the homecare visit consumption of the subscribing (n=335) and of a non-subscribing group (n=288)

were compared. Moreover, we interviewed care coordinators, clients, managers, and telenurses and observed the latter's work. Results show that the frequency of telehomecare contacts varied greatly. For this homecare client population the sheer provision of a video channel to nurses does not lead to substitution. Only for a few clients substitution of the regular homecare visits proved feasible The discussion section explains this disappointing outcome by technology push and an inconsistent implementation mode. It is argued that telehomecare can potentially serve four different goals, including substitution. For future research we propose consistent implementation modes to realize these goals. Varshney, U. (2009). "A framework for wireless monitoring of mental health conditions." Conference Proceedings: ... Annual International Conference of the IEEE Engineering in Medicine & Biology Society 2009: 5219-5222. Mental health management is fast becoming a major challenge worldwide as the incidence of mental illness has been increasing. It is affecting the quality of life as well as job productivity for a large number of people. Just like physical illnesses, people with mental illnesses can be monitored for a range of conditions and provided medical care as and when necessary. In this paper, we present an ITenabled framework to support mental health monitoring. This includes comprehensive monitoring of patients for symptoms, behavior, and medication compliance. We utilize context-awareness as a way to develop a system for mental health monitoring. Several examples of future mental health monitoring are also presented. Verhoeven, F., K. Tanja-Dijkstra, et al. (2010). "Asynchronous and synchronous teleconsultation for diabetes care: a systematic literature review." Journal of Diabetes Science & Technology 4(3): 666-684. AIM: A systematic literature review, covering publications from 1994 to 2009, was carried out to determine the effects of teleconsultation regarding clinical, behavioral, and care coordination outcomes of diabetes care compared to usual care. Two types of teleconsultation were distinguished: (1) asynchronous teleconsultation for monitoring and delivering feedback via email and cell phone, automated messaging systems, or other equipment without face-to-face contact; and (2) synchronous teleconsultation that involves real-time, face-to-face contact (image and voice) via videoconferencing equipment (television, digital camera, webcam, videophone, etc.) to connect caregivers and one or more patients simultaneously, e.g., for the purpose of education. METHODS: Electronic databases were searched for relevant publications about asynchronous and synchronous tele-consultation [Medline, Picarta, Psychinfo, ScienceDirect, Telemedicine Information Exchange, Institute for Scientific Information Web of Science, Google Scholar]. Reference lists of identified publications were hand searched. The contribution to diabetes care was examined for clinical outcomes [e.g., hemoglobin A1c (HbA1c), dietary values, blood pressure, quality of life], for behavioral outcomes (patient-caregiver interaction, self-care), and for care coordination outcomes (usability of technology, cost-effectiveness, transparency of guidelines, equity of access to care). Randomized controlled trials with HbA1c

as an outcome were pooled using standard meta-analytical methods. RESULTS: Of 2060 publications identified, 90 met inclusion criteria for electronic communication between (groups of) caregivers and patients with type 1 and 2 or gestational diabetes. Studies that evaluated teleconsultation not particularly aimed at diabetes were excluded, as were those that described interventions aimed solely at clinical improvements (e.g., HbA1c or lipid profiles). In 63 of 90 interventions, the interaction had an asynchronous teleconsultation character, in 18 cases interaction was synchronously (videoconferencing), and 9 involved a combination of synchronous with asynchronous interaction. Most of the reported improvements concerned clinical values (n = 49), self-care (n = 46), and satisfaction with technology (n = 43). A minority of studies demonstrated improvements in patient-caregiver interactions (n = 28) and cost reductions (n = 27). Only a few studies reported enhanced quality of life (n = 12), transparency of health care (n = 7), and improved equity in care delivery (n = 4). Asynchronous and synchronous applications appeared to differ in the type of contribution they made to diabetes care compared to usual care: asynchronous applications were more successful in improving clinical values and self-care, whereas synchronous applications led to relatively high usability of technology and cost reduction in terms of lower travel costs for both patients and care providers and reduced unscheduled visits compared to usual care. The combined applications (n = 9) scored best according to quality of life (22.2%). No differences between synchronous and asynchronous teleconsultation could be observed regarding the positive effect of technology on the quality of patient-provider interaction. Both types of applications resulted in intensified contact and increased frequency of transmission of clinical values with respect to usual care. Fifteen of the studies contained HbA1c data that permitted pooling. There was significant statistical heterogeneity among the pooled randomized controlled trials (chi(2) = 96.46, P < 0.001). The pooled reduction in HbA1c was not statically significant (weighted mean difference -0.10; 95% confidence interval -0.39 to 0.18). CONCLUSION: The included studies suggest that both synchronous and asynchronous teleconsultations for diabetes care are feasible, cost-effective, and reliable. However, it should be noted that many of the included studies showed no significant differences between control (usual care) and intervention groups. This might be due to the diversity and lack of quality in study designs (e.g., inaccurate or incompletely reported sample size calculations). Future research needs quasiexperimental study designs and a holistic approach that focuses on multilevel determinants (clinical, behavioral, and care coordination) to promote self-care and proactive collaborations between health care professionals and patients to manage diabetes care. Also, a participatory design approach is needed in which target users are involved in the development of cost-effective and personalized interventions. Currently, too often technology is developed within the scope of the existing structures of the health care system. Including patients as part of the design team stimulates and enables designers to think differently, unconventionally, or from a new perspective, leading to applications that are better tailored to patients' needs. (c) 2010 Diabetes Technology Society.

Verma, M., R. Raman, et al. (2009). "Application of tele-ophthalmology in remote diagnosis and management of adnexal and orbital diseases." Indian Journal of Ophthalmology 57(5): 381-384. PURPOSE: To assess the feasibility of making a diagnosis of adnexal and orbital diseases by Tele-ophthalmological means. MATERIALS AND METHODS: Teleconsultation for eye diseases was done for 3497 patients from remote areas of Tamilnadu as part of the rural tele-ophthalmology project of a tertiary eye care hospital during a period of nine months from October 2004 to June 2005. These patients were comprehensively examined on-site by optometrists. Using digitized images sent by store and forward technique and videoconferencing, the ophthalmologist made a diagnosis and advised treatment. RESULTS: Adnexal or orbital diseases were detected in 101 out of 3497 patients (2.88%). Medical treatment was advised to 13 of 101 patients (12.8%). Surgery was advised in 62 of 101 patients (61.28%) whereas 18 of 101 patients (17.8%) required further investigations at a tertiary center. CONCLUSION: It was feasible to apply the satellite based tele-ophthalmology set-up for making a presumptive diagnosis and planning further management of adnexal and orbital diseases based on live interaction and digital still images of the patients. Vernmark, K., J. Lenndin, et al. (2010). "Internet administered guided self-help versus individualized e-mail therapy: A randomized trial of two versions of CBT for major depression." Behaviour Research & Therapy 48(5): 368-376. Internet-delivered psychological treatment of major depression has been investigated in several trials, but the role of personalized treatment is less investigated. Studies suggest that guidance is important and that automated computerized programmes without therapist support are less effective. Individualized e-mail therapy for depression has not been studied in a controlled trial. Eighty-eight individuals with major depression were randomized to two different forms of Internet-delivered cognitive behaviour therapy (CBT), or to a waiting-list control group. One form of Internet treatment consisted of guided selfhelp, with weekly modules and homework assignments. Standard CBT components were presented and brief support was provided during the treatment. The other group received e-mail therapy, which was tailored and did not use the self-help texts i.e., all e-mails were written for the unique patient. Both treatments lasted for 8 weeks. In the guided self-help 93% completed (27/29) and in the e-mail therapy 96% (29/30) completed the posttreatment assessment. Results showed significant symptom reductions in both treatment groups with moderate to large effect sizes. At posttreatment 34.5% of the guided self-help group and 30% of the e-mail therapy group reached the criteria of highend-state functioning (Beck Depression Inventory score below 9). At six-month follow-up the corresponding figures were 47.4% and 43.3%. Overall, the difference between guided self-help and e-mail therapy was small, but in favour of the latter. These findings indicate that both guided self-help and individualized e-mail therapy can be effective. Copyright 2010 Elsevier Ltd. All rights reserved. Visser, J. J. W., J. K. C. Bloo, et al. (2010). "Video teleconsultation service: who is

needed to do what, to get it implemented in daily care?" Telemedicine Journal & EHealth 16(4): 439-445. INTRODUCTION: In telemedicine, technology is used to deliver services. Because of this, it is expected that various actors other than those involved in traditional care are involved in and need to cooperate, to deliver these services. The aim of this study was to establish a clear understanding of these actors and their roles and interrelationships in the delivery of telemedicine. A video teleconsultation service is used as a study case. METHODS: A business modeling approach as described in the Freeband Business Blueprint Method was used. The method brings together the four domains that make up a business model, that is, service, technology, organization, and finance, and covers the integration of these domains. The method uses several multidisciplinary workshops, addressing each of the four domains. RESULTS: Results of the four domains addressed showed that (1) the video teleconsultation service is a store and put-forward video teleconsult for healthcare providers. The service is accepted and has added value for the quality of care. However, the market is small; (2) the technology consists of a secured Internet Web-based application, standard personal computer, broadband Internet connection, and a digital camera; (3) a new role and probably entity, responsible for delivering the integrated service to the healthcare professionals, was identified; and finally (4) financial reimbursement for the service delivery is expected to be most successful when set up through healthcare insurance companies. Pricing needs to account for the fee of healthcare professionals as well as for technical aspects, education, and future innovation. DISCUSSION: Implementation of the video teleconsult service requires multidisciplinary cooperation and integration. Challenging aspects are the small market size and the slow implementation speed, among others. This supports the argument that accumulation of several telemedicine applications is necessary to make it financially feasible for at least some of the actors. Vitacca, M., L. Comini, et al. (2010). "A pilot trial of telemedicine-assisted, integrated care for patients with advanced amyotrophic lateral sclerosis and their caregivers." Journal of Telemedicine & Telecare 16(2): 83-88. Patients with amyotrophic lateral sclerosis (ALS) need a care programme as the disease progresses. We used telemedicine-assisted integrated care (TAIC) in 40 patients with ALS, for a mean duration of 8.6 months (range 1-12). A nurse-tutor played the key role, supported by respiratory physicians, neurologists and psychologists. Each patient used a portable pulse oximeter during the daily telephone contacts to assess clinical/oxygen variations. Patients also completed a satisfaction questionnaire. During the study period, each patient used TAIC at least five times per month. There were 1907 scheduled telephone calls (86% of the total) and 317 unscheduled calls. Of the unscheduled calls, 84% were managed by the nurse-tutor and only 16% of them required specialist intervention. The most common item was the ALS clinical interview (58%), followed by the description of acute symptoms, cough ability and oxygenation. TAIC staff recommended 4 out of 12 emergency hospital admissions (33%) and

77% of the other hospitalizations. Patients and caregivers were extremely satisfied (79%) with the nurse assistance provided and the patients' confidence in handling their disease improved in 71% of the cases. TAIC provides a nursecentred, home-monitoring programme that can be a useful way of following up ALS patients. Vuononvirta, T., M. Timonen, et al. (2009). "The attitudes of multiprofessional teams to telehealth adoption in northern Finland health centres." Journal of Telemedicine & Telecare 15(6): 290-296. A telehealth network was established between seven health centres, the local university and the university hospital in the Oulu Arc Subregion in a rural area of northern Finland. During the period 2004-2007, the videophone network was used for different types of teleconsultation (orthopaedics, psychiatry, diabetes, rehabilitation), continuing education and various patient care and administrative meetings. Qualitative research with observation and interviews with 30 professionals (physicians, nurses, psychiatric nurses, physiotherapists) was carried out in early 2007 to find out health-care professionals' attitudes toward telehealth and to see how the attitudes were connected to telehealth usage. Overall, the attitudes were more positive than negative, ranging from negative to enthusiastically positive. Diversity of attitudes occurred in relation to time, situation, profession, health centre and telehealth application. Ten different types of telehealth adopters were recognized: enthusiastic user, positive user, critical user, hesitant user, positive participant, hesitant participant, critical participant, neutral participant, negative participant and positive non-participant. Telehealth was especially well accepted in continuing education and in diabetes teleconsultations. The study showed that a negative attitude was not a definite barrier to telehealth adoption, but it did require additional attention from project workers and managers. Project staff and managers need to take into account the diverse attitudes of health professionals, because different people require different actions to adopt telehealth in their work. Wade, V., J. Eliott, et al. (2010). "A qualitative study of sustainability and vulnerability in Australian telehealth services." Studies in Health Technology & Informatics 161: 190201. The uptake of telehealth into the ongoing and routine operations of healthcare has been slow, uneven and fragmented. Research has focused on the initial adoption and diffusion of telehealth, with much less known about sustainability. This study made a qualitative inquiry into the sustainability of a diverse sample of ceased and continuing telehealth services in Australia, asking why services ceased, and how continuing services were either vulnerable or sustainable. Fifty four Australian telehealth services were identified in the academic literature over a ten year period between 1998 and 2007. A sample of these was chosen for maximum variation, and 36 semi-structured interviews were conducted concerning 35 telehealth services. Of these services, 8 had ceased, 14 were vulnerable, 10 sustainable, and 3 could not be classified. The major theme from ceased services was lack of support and insufficient demand from participating

sites. Vulnerabilities identified from operating sites were reliance on a single person, low levels of interest, short-term funding, and difficulties making the transition from research to service. Sustainable services had two main models of functioning: to reach a sufficient size and flow of referrals to justify dedicated staffing, coordination and infrastructure; or, to fit a lower level of telehealth activity into an existing clinical setting. Sustainability of telehealth services can be enhanced by choosing an operating model appropriate to the size of the service, meeting the needs of and developing good relationships with referring services, raising awareness, and succession planning. Wade, V. A., J. Karnon, et al. (2010). "A systematic review of economic analyses of telehealth services using real time video communication." BMC Health Services Research 10: 233. BACKGROUND: Telehealth is the delivery of health care at a distance, using information and communication technology. The major rationales for its introduction have been to decrease costs, improve efficiency and increase access in health care delivery. This systematic review assesses the economic value of one type of telehealth delivery--synchronous or real time video communication--rather than examining a heterogeneous range of delivery modes as has been the case with previous reviews in this area. METHODS: A systematic search was undertaken for economic analyses of the clinical use of telehealth, ending in June 2009. Studies with patient outcome data and a nontelehealth comparator were included. Cost analyses, non-comparative studies and those where patient satisfaction was the only health outcome were excluded. RESULTS: 36 articles met the inclusion criteria. 22(61%) of the studies found telehealth to be less costly than the non-telehealth alternative, 11(31%) found greater costs and 3 (9%) gave the same or mixed results. 23 of the studies took the perspective of the health services, 12 were societal, and one was from the patient perspective. In three studies of telehealth to rural areas, the health services paid more for telehealth, but due to savings in patient travel, the societal perspective demonstrated cost savings. In regard to health outcomes, 12 (33%) of studies found improved health outcomes, 21 (58%) found outcomes were not significantly different, 2(6%) found that telehealth was less effective, and 1 (3%) found outcomes differed according to patient group. The organisational model of care was more important in determining the value of the service than the clinical discipline, the type of technology, or the date of the study. CONCLUSION: Delivery of health services by real time video communication was cost-effective for home care and access to on-call hospital specialists, showed mixed results for rural service delivery, and was not cost-effective for local delivery of services between hospitals and primary care. Waite, M. C., D. G. Theodoros, et al. (2010). "Internet-based telehealth assessment of language using the CELF-4." Language, Speech & Hearing Services in the Schools 41(4): 445-458. PURPOSE: Telehealth has the potential to improve children's access to speechlanguage pathology services. Validation of telehealth applications, including the

assessment of childhood language disorders, is necessary for telehealth to become an accepted alternative mode of service provision. The aim of this study was to validate an Internet-based telehealth system for assessing childhood language disorders. METHOD: Twenty-five children ages 5 to 9 years were assessed using the core language subtests of the Clinical Evaluation of Language Fundamentals--4th Edition (CELF-4; Semel, Wiig, & Secord, 2003). Each participant was simultaneously assessed online and face-to-face (FTF). Assessments were administered by either an online or an FTF speech-language pathologist (SLP), but were simultaneously rated by both SLPs. RESULTS: No significant difference was found between the online and FTF total raw scores and scaled scores for each subtest. Weighted kappas revealed very good agreement on the individual items, total raw scores, scaled scores, core language score, and severity level. Intra- and interrater reliability were determined for a sample of online ratings, with intraclass correlation analysis revealing very good agreement on all measures. CONCLUSION: The results of this study support the validity and reliability of scoring the core language subtests of the CELF-4 via telehealth. Watson, A. J., H. Bergman, et al. (2010). "A randomized trial to evaluate the efficacy of online follow-up visits in the management of acne." Archives of Dermatology 146(4): 406-411. OBJECTIVE: To evaluate whether delivering acne follow-up care via an asynchronous, remote online visit (e-visit) platform produces equivalent clinical outcomes to office care. DESIGN: A prospective, randomized controlled study. SETTING: Two teaching hospitals in Boston between September 2005 and May 2007. PARTICIPANTS: A total of 151 patients with mild to moderate facial acne. INTERVENTIONS: Subjects were asked to carry out 4 follow-up visits using either an e-visit platform or conventional office care. At 6-week intervals, subjects in the e-visit group were prompted to send images of their skin and an update, via a secure Web site, to their dermatologist. Dermatologists responded with advice and electronic prescriptions. MAIN OUTCOME MEASURES: The primary outcome measure was change in total inflammatory lesion count between the first and last visit. The major secondary outcomes were subject and dermatologist satisfaction with care and length of time to complete visits. RESULTS: The mean age of subjects was 28 years; most were female (78%), white (65%), and college educated (69%). One hundred twenty-one of the initial 151 subjects completed the study. The decrease in total inflammatory lesion count was similar in the e-visit and office visit groups (6.67 and 9.39, respectively) (P = .49). Both subjects and dermatologists reported comparable satisfaction with care regardless of visit type (P = .06 and P = .16, respectively). Compared with office visits, e-visits were time saving for subjects and time neutral for dermatologists (4 minutes, 8 seconds vs 4 minutes, 42 seconds) (P = . 57). CONCLUSION: Delivering follow-up care to acne patients via an e-visit platform produced clinical outcomes equivalent to those of conventional office visits. Weinstein, R. S., A. M. Lopez, et al. (2008). "Integrating telemedicine and telehealth:

putting it all together." Studies in Health Technology & Informatics 131: 23-38. Telemedicine and telehealth programs are inherently complex compared with their traditional on-site health care delivery counterparts. Relatively few organizations have developed sustainable, multi-specialty telemedicine programs, although single service programs, such as teleradiology and telepsychiatry programs, are common. A number of factors are barriers to the development of sustainable telemedicine and telehealth programs. First, starting programs is often challenging since relatively few organizations have, in house, a critical mass of individuals with the skill sets required to organize and manage a telemedicine program. Therefore, it is necessary to "boot strap" many of the start-up activities using available personnel. Another challenge is to assemble a management team that has time to champion telemedicine and telehealth while dealing with the broad range of issues that often confront telemedicine programs. Telemedicine programs housed within a single health care delivery system have advantages over programs that serve as umbrella telehealth organizations for multiple health care systems. Planning a telemedicine program can involve developing a shared vision among the participants, including the parent organizations, management, customers and the public. Developing shared visions can be a time-consuming, iterative process. Part of planning includes having the partnering organizations and their management teams reach a consensus on the initial program goals, priorities, strategies, and implementation plans. Staffing requirements of telemedicine and telehealth programs may be met by sharing existent resources, hiring additional personnel, or outsourcing activities. Business models, such as the Application Service Provider (ASP) model used by the Arizona Telemedicine Program, are designed to provide staffing flexibility by offering a combination of in-house and out-sourced services, depending on the needs of the individual participating health care organizations. Telemedicine programs should perform ongoing assessments of activities, ranging from service usage to quality of service assessments, to ongoing analyses of financial performance. The financial assessments should include evaluations of costs and benefits, coding issues, reimbursement, account receivables, bad debt and network utilization. Long-range strategic planning for a telemedicine and telehealth program should be carried out on an on-going basis and should include the program's governing board. This planning process should include goal setting and the periodic updating of the program's vision and mission statements. There can be additional special issues for multi-organization telemedicine and telehealth programs. For example, authority management can require the use of innovative approaches tailored to the realities of the organizational structures of the participating members. Inter-institutional relations may introduce additional issues when competing health care organizations are utilizing shared resources. Branding issues are preferably addressed during the initial planning of a multi-organizational telemedicine and telehealth program. Ideally, public policy regarding telemedicine and telehealth within a service region will complement the objectives of telemedicine and telehealth programs within that service area.

Wilkinson, T. J., J. D. Smith, et al. (2008). "Structured assessment using multiple patient scenarios by videoconference in rural settings." Medical Education 42(5): 480-487. CONTEXT: The assessment blueprint of the Australian College of Rural and Remote Medicine postgraduate curriculum highlighted a need to assess clinical reasoning. We describe the development, reliability, feasibility, validity and educational impact of an 8-station assessment tool, StAMPS (structured assessment using multiple patient scenarios), conducted by videoconference. METHODS: StAMPS asks each candidate to be examined at each of 8 stations on issues relating to patient diagnosis or management. Each candidate remains located in a rural site but is examined in turn by 8 examiners who are located at a central site. Examiners were rotated through the candidates by either walking between videoconference rooms or by connecting and disconnecting the links. Reliability was evaluated using generalisability theory. Validity and educational impact were evaluated with qualitative interviews. RESULTS: Fourteen candidates were assessed on 82 scenarios with a reliability of G = 0.76. There was a reasonable correlation with level of candidate expertise (rho = 0.57). The videoconference links were acceptable to candidates and examiners but the walking rotation system was more reliable. Qualitative comments confirmed relevance and acceptability of the assessment tool and suggest it is likely to have a desirable educational impact. CONCLUSIONS: StAMPS not only reflects the content of rural and remote practice but also reflects the process of that work in that it is delivered from a distance and assesses resourcefulness and flexibility in thinking. The reliability and feasibility of this type of assessment has implications for people running any distance-based course, but the assessment could also be used in a face-to-face setting. Williams, T., C. May, et al. (2003). "Normative models of health technology assessment and the social production of evidence about telehealth care." Health Policy 64(1): 39-54. Telehealthcare is a rapidly growing field of clinical activity and technical development. These new technologies have caught the attention of clinicians and policy makers because they seem to offer more rapid access to specialist care, and the potential to solve structural problems around inequalities of service provision and distribution. However, as a field of clinical practice, telehealthcare has consistently been criticised because of the poor quality of the clinical and technical evidence that its proponents have marshalled. The problem of "evidence" is not a local one. In this paper, we undertake two tasks: first, we critically contrast the normative expectations of the wider field of Health Technology Assessment (HTA) with those configured within debates about Telehealthcare Evaluation; and second, we critically review models that provide structures within which the production of evidence about telehealthcare can take place. Our analysis focuses on the political projects configured within a literature aimed at stabilising evaluative knowledge production about telehealthcare in the face of substantial political and methodological problems. [References: 44] Wilson, L. S., D. R. Stevenson, et al. (2010). "Telehealth on advanced networks." Telemedicine Journal & E-Health 16(1): 69-79.

We address advanced Internet for complex telehealth applications by reviewing four hospital-based broadband telehealth projects and identifying common threads. These projects were conducted in Australia under a 6-year research project on broadband Internet applications. Each project addressed specific clinical needs and its development was guided by the clinicians involved. Each project was trialed in the field and evaluated against the initial requirements. The four projects covered remote management of a resuscitation team in a district hospital, remote guidance and interpretation of echocardiography, virtual-realitybased instructor-student surgical training, and postoperative outpatient consultations following pediatric surgery. Each was characterized by a high level of interpersonal communication, a high level of clinical expertise, and multiple participants. Each made use of multiple high-quality video and audio links and shared real-time access to clinical data. Four common threads were observed. Each application provided a high level of usability and task focus because the design and use of broadband capability was aimed directly to meet the clinicians' needs. Each used the media quality available over broadband to convey words, gestures, body movements, and facial expressions to support communication and a sense of presence among the participants. Each required a complex information space shared among the participants, including real-time access to stored patient data and real-time interactive access to the patients themselves. Finally, each application supported the social and organizational aspects of their healthcare focus, creating and maintaining relationships between the various participants, and this was done by placing the telehealth application into a wider functioning clinical context. These findings provide evidence for a significantly enhanced role for appropriate telemedicine systems running on advanced networks, in a wider range of clinical applications, more deeply integrated into healthcare systems. Witmans, M. B., B. Dick, et al. (2008). "Delivery of pediatric sleep services via telehealth: the Alberta experience and lessons learned." Behavioral Sleep Medicine 6(4): 207-219. Concerns regarding a child's sleep, identified by a caregiver or by the health care practitioner, are commonly raised but often left unexplored. Families in geographically isolated areas, with limited access to specialty services such as pediatric sleep medicine, are at increased risk for unmet treatment needs. Telehealth is a potential vehicle for delivery of these specialty services and overcoming barriers in diagnosing and treating sleep disorders in children by improving access and enhancing support for the families in their communities. This article describes the initiation of a pilot program in the delivery of multidisciplinary pediatric sleep medicine services via telehealth in Alberta, Canada. Wu, Y., Z. Wei, et al. (2010). "TeleOph: a secure real-time teleophthalmology system." IEEE Transactions on Information Technology in Biomedicine 14(5): 1259-1266. Teleophthalmology (TeleOph) is an electronic counterpart of today's face-to-face, patient-to-specialist ophthalmology system. It enables one or more

ophthalmologists to remotely examine a patient's condition via a confidential and authentic communication channel. Specifically, TeleOph allows a trained nonspecialist in a primary clinic to screen the patients with digital instruments (e.g., camera, ophthalmoscope). The acquired medical data are delivered to the hospital where an ophthalmologist will review the data collected and, if required, provide further consultation for the patient through a real-time secure channel established over a public Internet network. If necessary, the ophthalmologist is able to further sample the images/video of the patient's eyes remotely. In order to increase the productivity of the ophthalmologist in terms of number of patients reviewed, and to increase the efficiency of network resource, we manage the network bandwidth based on a Poisson model to estimate patient arrival at the clinics, and the rate of ophthalmologist consultation service for better overall system efficiency. The main objective of TeleOph is therefore to provide the remote patients with a cost-effective access to specialist's eye checkups at primary healthcare clinics, and at the same time, minimize unnecessary face-toface consultation at the hospital specialist's center. Wurm, E. M. T., R. Hofmann-Wellenhof, et al. (2008). "Telemedicine and teledermatology: Past, present and future." Journal der Deutschen Dermatologischen Gesellschaft 6(2): 106-112. Telemedicine is an emerging field within medicine with potential to revolutionize the delivery of health care. It is defined as the use of telecommunication technologies to transfer medical information. Teledermatology is a category of telemedicine. Early experiments were already made at the beginning of the 20(th) century, the breakthrough happened in the nineties because of the rapid progress of telecommunication technology. The latest advance is mobile telemedicine which is characterized by the use of mobile devices such as mobile phone and PDA (personal digital assistant). Advantages of telemedicine are the possibility of remote patient-care as well as the easy and fast access to expert opinions and education. This can either happen through exchange of previously stored data/images (store-and-forward method) or in real time. Since our society is increasingly becoming interconnected via technical advances, it is essential that medicine also has an objective understanding of the topic. [References: 41] Yang, C.-W., H.-C. Wang, et al. (2008). "Impact of adding video communication to dispatch instructions on the quality of rescue breathing in simulated cardiac arrests--a randomized controlled study." Resuscitation 78(3): 327-332. OBJECTIVE: Both ventilations and compressions are important for victims of prolonged cardiopulmonary resuscitation (CPR) and asphyxial arrest. Dispatch assistance increases bystander CPR, but the quality of dispatcher-assisted CPR (DA-CPR), especially rescue breathing, remains unsatisfactory. This study was conducted to assess the impact of adding interactive video communication to dispatch instructions on the quality of rescue breathing in simulated cardiac arrests. METHODS: In this simulation-based study, adults without CPR training within 5 years were recruited between April and July 2007 and randomized to receive dispatch assistance with either voice instruction alone (voice group,

n=53) or interactive voice and video instruction (video group, n=43) via a video cell phone. The quality of rescue breathing was evaluated by reviewing the videos and mannequin reports. RESULTS: Subjects in the video group were more likely to open the airway correctly (95.3% vs. 58.5%, P<0.01) and to lift the chin properly (95.3% vs. 62.3%, P<0.01), but had similar rates of head-tilt (95.3% vs. 84.9%, P=0.10). Volunteers in the video group had larger volume of ventilation (median volume 540 ml vs. 0 ml, P<0.01), greater possibility to sustain an open airway (88.4% vs. 60.4%, P<0.01) and a tendency towards better nosepinch (97.7% vs. 86.8%, P=0.06). The video group spent longer time to open the airway (59 s vs. 56 s, P<0.05) and to give the first rescue breathing (139 s vs. 102 s, P<0.01). CONCLUSION: Adding video communication to dispatch instructions improved the quality of bystander rescue breathing, including higher proportion of airway opened, and larger volume of ventilation delivered, in simulated cardiac arrests. Yardley, L., J. Joseph, et al. (2010). "Evaluation of a Web-based intervention providing tailored advice for self-management of minor respiratory symptoms: exploratory randomized controlled trial." Journal of Medical Internet Research 12(4): e66. BACKGROUND: There has been relatively little research on the role of webbased support for self-care in the management of minor, acute symptoms, in contrast to the wealth of recent research into Internet interventions to support self-management of long-term conditions. OBJECTIVE: This study was designed as an evaluation of the usage and effects of the "Internet Doctor" website providing tailored advice on self-management of minor respiratory symptoms (eg, cough, sore throat, fever, runny nose), in preparation for a definitive trial of clinical effectiveness. The first aim was to evaluate the effects of using the Internet Doctor webpages on patient enablement and use of health services, to test whether the tailored, theory-based advice provided by the Internet Doctor was superior to providing a static webpage providing the best existing patient information (the control condition). The second aim was to gain an understanding of the processes that might mediate any change in intentions to consult the doctor, by comparing changes in relevant beliefs and illness perceptions in the intervention and control groups, and by analyzing usage of the Internet Doctor webpages and predictors of intention change. METHODS: Participants (N = 714) completed baseline measures of beliefs about their symptoms and self-care online, and were then automatically randomized to the Internet Doctor or control group. These measures were completed again by 332 participants after 48 hours. Four weeks later, 214 participants completed measures of enablement and health service use. RESULTS: The Internet Doctor resulted in higher levels of satisfaction than the control information (mean 6.58 and 5.86, respectively; P = .002) and resulted in higher levels of enablement a month later (median 3 and 2, respectively; P = .03). Understanding of illness improved in the 48 hours following use of the Internet Doctor webpages, whereas it did not improve in the control group (mean change from baseline 0.21 and -0.06, respectively, P = .05). Decline in intentions to consult the doctor between baseline and follow-up was predicted by age (beta = .10, P= .003), believing before accessing the website

that consultation was necessary for recovery (beta = .19, P < .001), poor understanding of illness (beta = .11, P = .004), emotional reactions to illness (beta = .15, P <.001), and use of the Diagnostic section of the Internet Doctor website (beta = .09, P = .007). CONCLUSIONS: Our findings provide initial evidence that tailored web-based advice could help patients self-manage minor symptoms to a greater extent. These findings constitute a sound foundation and rationale for future research. In particular, our study provides the evidence required to justify carrying out much larger trials in representative population samples comparing tailored web-based advice with routine care, to obtain a definitive evaluation of the impact on self-management and health service use. Yu, H. and Y.-G. Cao (2008). "Automatically extracting information needs from Ad Hoc clinical questions." AMIA .. Annual Symposium Proceedings/AMIA Symposium.: 96100. Automatically extracting information needs from ad hoc clinical questions is an important step towards medical question answering. In this work, we first explored supervised machine-learning approaches to automatically classify an ad hoc clinical question into general topics. We then evaluated different methods for automatically extracting keywords from an ad hoc clinical question. Our methods were evaluated on the 4,654 clinical questions maintained by the National Library of Medicine. Our best systems or methods showed F-score of 76% for the task of question-topic classification and an average F-score of 56% for extracting keywords from ad hoc clinical questions. Zanaboni, P., S. Scalvini, et al. (2009). "Teleconsultation service to improve healthcare in rural areas: acceptance, organizational impact and appropriateness." BMC Health Services Research 9: 238. BACKGROUND: Nowadays, new organisational strategies should be identified to improve primary care and its link with secondary care in terms of efficacy and timeliness of interventions thus preventing unnecessary hospital accesses and costs saving for the health system. The purpose of this study is to assess the effects of the use of teleconsultation by general practitioners in rural areas. METHODS: General practitioners were provided with a teleconsultation service from 2006 to 2008 to obtain a second opinion for cardiac, dermatological and diabetic problems. Access, acceptance, organisational impact, effectiveness and economics data were collected. Clinical and access data were systematically entered in a database while acceptance and organisational data were evaluated through ad hoc questionnaires. RESULTS: There were 957 teleconsultation contacts which resulted in access to health care services for 812 symptomatic patients living in 30 rural communities. Through the teleconsultation service, 48 general practitioners improved the appropriateness of primary care and the integration with secondary care. In fact, the level of concordance between intentions and consultations for cardiac problems was equal to 9%, in 86% of the cases the service entailed a saving of resources and in 5% of the cases, it improved the timeliness. 95% of the GPs considered the overall quality positively. For a future routine use of this service, trust in specialists, duration and workload

of teleconsultations and reimbursement should be taken into account. CONCLUSIONS: Managerial and policy implications emerged mainly related to the support to GPs in the provision of high quality primary care and decisionmaking processes in promoting similar services. Zartner, P., R. Handke, et al. (2008). "Performance of an autonomous telemonitoring system in children and young adults with congenital heart diseases." Pacing & Clinical Electrophysiology 31(10): 1291-1299. BACKGROUND: Integrated telemonitoring systems controlling circulatory and electrical parameters in adults with an implanted pacemaker have shown to be advantageous during follow-up of this patient group. In children and young adults with a congenital heart disease (CHD), these systems have to cope with a diversity of varying arrhythmias and a broad range of intrinsic cardiac parameters. Additional problems arise from the patients' growth and anatomic anomalies. METHODS: Since 2005, eight young patients (age 4.1- 37 years, mean 15.5 years) with a CHD received a pacemaker or implantable cardioverter defibrillator with an autonomous telemonitoring system at our clinic. The mean follow-up time was 395 days (range 106-834 days, 8.7 patient years). RESULTS: In seven of eight patients the system transmitted information, which led to beneficial modifications of the current antiarrhythmic therapy. In three patients the reported events were of a critical nature. One patient remained event-free for 192 days after implantation. During follow-up, 96% of the days were covered. The system also transferred additional information on the effectiveness of antiarrhythmic medication and the impact of physical activity. CONCLUSIONS: Young patients with an insufficient intrinsic heart rate or progressing arrhythmia, in addition to the conventional indications for pacemaker or defibrillator implantation, seem to profit to a high percentage from a telemetric surveillance system. The fully automated procedure of device interrogation and information transmission gives a daily overview on system function and specific arrhythmic events, especially in children who are unaware of any symptoms. Zetterman, C. V., B. J. Sweitzer, et al. (2011). "Validation of a virtual preoperative evaluation clinic: a pilot study." Studies in Health Technology & Informatics 163: 737739. Patients scheduled for surgery at the Omaha VA Medical Center were evaluated preoperatively via telemedicine. Following the examination, patients filled out a 15 item, 5 point Likert scale questionnaire regarding their opinion of preoperative evaluation in a VTC format. Evaluations were performed under the direction of nationally recognized guidelines and recommendations of experts in the field of perioperative medicine and were overseen by a staff anesthesiologist from the Omaha VA Medical Center. No significant difficulties were encountered by the patient or the evaluator regarding the quality of the audio/visual capabilities of the VTC link and its ability to facilitate preoperative evaluation. 87.5% of patients felt that virtual evaluation would save them travel time; 87.5% felt virtual evaluation could save them money; 7.3% felt uncomfortable using the VTC link; 12.2% felt the virtual evaluation took longer than expected; 70.7% preferred to be evaluated

via VTC link; 21.9% were undecided; 9.7% felt they would rather be evaluated face-to-face with 26.8% undecided; 85.0% felt that teleconsultation was as good as being seen at the Omaha surgical evaluation unit; 7.5% were undecided. Our study has shown that effective preoperative evaluation can be performed using a virtual preoperative evaluation clinic; patients are receptive to the VTC format and, in the majority of cases, prefer it to face-to-face evaluation. Association, A. T. (2009). Recommendations for Implementation of Funds Provided within the American Recovery and Reinvestment Act of 2009, American Telemedicine Association The ATA suggests that the funds viable be used to; expand the broadband infrastructure, expand telemedicine and remote monitoring networks to improve access, coordination within institutions to on telecommunication and Telemedicine efforts., export of health services and disaster response. It also lists some of the funding sources.

Brewer, R., G. Goble, et al. (2011). "A peach of a telehealth program: Georgia connects rural communities to better healthcare." Perspect Health Inf Manag 8: 1c. This article presents Georgia's telehealth response to some of the significant healthcare challenges and disparities facing the rural citizens of this state. When compared to their urban and suburban counterparts, rural communities have fewer healthcare providers, and residents must travel longer distances to reach them. Georgia's statewide telemedicine network, the Georgia Partnership for TeleHealth (GPT), uses information technology to improve the efficiency and quality of healthcare and health outcomes for underserved populations in Georgia. Burke, B., Jr., A. Bynum, et al. (2008). "Rural school-based telehealth: how to make it happen." Clin Pediatr (Phila) 47(9): 926-929. When organizing new health care interventions among a rural population, a careful planning process respecting community-specific considerations should be used. The project objective centered on the successful implementation of a school-based telehealth clinic serving a rural, health-disparate population. Using an American Academy of Pediatrics Community Access to Child Health planning grant, a needs assessment of the Delta community was conducted. In synthesizing the results of this planning project, consensually addressed issues led to establishing a pilot school-based telehealth clinic within the rural county schools. Seven essential steps emerged as a set of guidelines that entities might consider in introducing a telemedicine school-based service in a rural community. The steps included assessing local and regional needs, securing community support and establishing goals, evaluating resources, configuring logistics, training staff, informing parents, and launching the clinic. Proper planning is crucial to the establishment of a rural school-based telehealth clinic.

CISCO (2011). "CISCO HealthPresence SolutionDesign Guide." This is corporate/vendor guide published by CISO on over deign of video conferencing for the health care sector. It is a design guide for construction of appropriate data center resources, end-point equipment, band-width requirements, security, and room design Duesterhoeft, T. (2009). "The Future of Telehealth Monitoring Innovations in remote patient care and their implications for the health care industry." Caring - National Association for Home Care & Hospice July: 4447. The article argues that evidence from the Framingham study indicates that relatively small changes in weight and blood pressure cause problems for CHF patient and that improved monitoring will reduce hospitalizations. He further stated that at $4800 per day reduction in readmission substantially lower the costs of care. He presents evidence from several organizations that utilize home monitoring that this cost reduction can be realized. He blames current reimbursement policies for the lack of wide scale deployment. Editor, E. W. C. (2010). Vidyo unveils new telemedicine platform. Healthcare IT News. This was reporting Vidyo announcement of a new video architecture April 0 2010. This architecture allows the product to be deployed across pc, smart phone and tablets and supports multi-point conferencing without the necessity of an MCU. It also mention early adopted of the technology. Gartner, I. (2011). Hype Cycle for Telemedicine, Inc. Gartner uses a proprietary evaluation called a "Hype Cycle". It is one way of looking at a technology and determining whether it is mature or just in its infancy. There is also a period called "the trough of Disillusionment. Rather than being pejorative this describes coming to terms with actual uses of the technology versus the hype. With respect to real-time virtual visits Gartner rates this activity as relatively in its infancy, whereas e-visits (asynchronous) are on their way to maturity, Gartner, I. (2011). Markets For Telepresence and Group Video Systems. This white paper evaluates the major vendors in telepresence. It uses Business, Customer Experience, Market responsiveness, Marketing Execution, Product/Service and Overall Viability as criteria. It is not specific to healthcare but coverers the major players in this field, CISCO, LifeSize, Polycom, Tandberg. As well it gives a good review of VIDYO, Inc a venture start-up with a new video conferencing network. Greene, T. (2011) Mass. General Hospital revamps video gear; bolsters telemedicine program. Network World Essentially a press release with some staff writer commentary. This article talks

about Mass General contracting with Vidyo to provide video conferencing technology. Mass General has a sizable telemedicine program that has used large scale room systems and MCU's for multi-point conference. The Vidyo architecture will allow Mass General an inexpensive scalable solution INC, V. (2011). "Who's First? The Race for Mobile Conferencing." This article attempts to differentiate VIDYO. Inc's architectural differences from Polycom, LIfeSIze, and Tandberg in terms of platform support and argues that this is key to making video conferencing useful. LifeSize a Division of Logitech, I. (2010). An Overview of Considerations for Healthcare IT Managers. This is a fairly basic guide for IT mangers to understand the uses and deployment strategies for video conferencing in healthcare and telemedicine. It states the chief standards that must be present in any product that is considered and provides a basic guide to designing new systems. Luptak, M., N. Dailey, et al. (2010). "The Care Coordination Home Telehealth (CCHT) rural demonstration project: a symptom-based approach for serving older veterans in remote geographical settings." Rural Remote Health 10(2): 1375. INTRODUCTION: Innovative healthcare delivery strategies are needed to address the healthcare needs of the 3.5 million older veterans living in US rural areas who face unique healthcare delivery challenges, including transportation barriers, poverty, and limited access to health professions and community-based programs. The care coordination home telehealth (CCHT) rural demonstration project was developed to address the mismatch between the timely identification of patient needs and the care delivered by the traditional disease-oriented institutionally-based healthcare delivery system for older rural veterans. The specific objectives were to: (1) serve as a facilitator of primary care; and (2) provide a portfolio of geriatric care management options to increase early detection of symptoms and to encourage adherence to care plans. METHODS: Participants were recruited based on patterns of high outpatient, inpatient, and emergency care visits; 132 rural older veterans were enrolled. The CCHT applied care management principles to the delivery of healthcare services and used health informatics to facilitate access to evidence-based care. The CCHT's essential components, which were tailored to optimize remote access, included a face-to-face orientation, telephone contact with a designated care coordinator, and daily monitoring sessions using an in-home telehealth device to assess participants' medication usage, compliance, and symptoms, and to provide patient education. RESULTS: One hundred eleven participants successfully installed and connected the telehealth monitoring device in their homes without hands-on assistance, monitored complex medical and psychiatric symptoms, and reported medication compliance remotely. Of the 93 participants who used the device for more than 10 sessions, 88 reported they did not have any difficulty using the device, 86 reported they were satisfied or very satisfied with the device, 73 reported they were likely to continue using the device, and 46 reported

improved communication between themselves and their primary healthcare provider. CONCLUSION: Initial utilization and satisfaction evaluation data from this project supports the feasibility of employing a CCHT approach to serve medically-complicated older veterans in rural settings. This approach could also serve as a template for addressing a greater range of healthcare needs among other populations in hard-to-reach settings. Network, I. T. (2009). "Video Conferencing Essentials." This is an excellent basic primer for implementing a rural telehealth solution. It is a bit sparse on some details, particularly information regarding re-imbursement, sustainability and pricing. The appendices provide some supporting details. Scott, A., L. D. Woodhouse, et al. (2011). "The Southeast Telehealth Network: using technology to overcome the barriers to rural public health practice." J Public Health Manag Pract 17(2): 164-166. This is the first systematic report on using a telehealth network being used systematically for public health practice with a state agency to deliver health promotion services. It concludes that within one year over $290,000 in mileage reimbursements and salary cost had been saved in the 16 participating counties. Shore, J. H., E. Brooks, et al. (2007). "An economic evaluation of telehealth data collection with rural populations." Psychiatr Serv 58(6): 830-835. OBJECTIVE: This study compared direct costs of conducting structured clinical interviews via real-time interactive videoconferencing (known as telehealth) versus standard in-person methods with American Indians in rural locations. METHODS: Psychiatrists administered in person and via telehealth on two occasions the Structured Clinical Interview for DSM-III-R to 53 non-VA male, American-Indian veterans. Telehealth interviews were conducted by an integrated services digital network (ISDN) connection at 384 kbps. Direct costs were compared for the two interview modalities. Models for starting telehealth in new clinics and established clinics were created, and the models were further subdivided to examine 2003 and 2005 differences in transmission fees. Direct costs included transmission, personnel, travel, and equipment (where applicable). RESULTS: The model of conducting interviews via telehealth in new clinics cost about $6,000 more than in-person interviews in 2003. However, reduced transmission fees and a different videoconferencing setup resulted in telehealth interviews' costing $8,000 less than in-person interviews in 2005. The same pattern held true for the model for established clinics. Telehealth interviews cost $1,700 more than in-person interviews in 2003 but $12,000 less in 2005. Scenarios using non-physician interviewers and current, rather than historical, transmission costs favored telehealth as a cost-effective means for clinical research. CONCLUSIONS: On the basis of current transmission costs, telehealth proved less expensive than in-person interviews. Telehealth may therefore increase the efficiency and decrease the cost of research with rural, remote, and underserved populations, facilitating the ease with which one can investigate health disparities in these otherwise neglected settings.

SInger, E. (2011). "How the Health Care System Slows Mobile Medical Technology." Technology Review MIT. The article argues that although wireless patient monitoring devices continue to be cheaper and better that they have a very slow uptake. This is due to current reimbursement policies. Singh, R., L. Mathiassen, et al. (2010). "Sustainable rural telehealth innovation: a public health case study." Health Serv Res 45(4): 985-1004. OBJECTIVE: To examine adoption of telehealth in a rural public health district and to explain how the innovation became sustainable. STUDY SETTING: Longitudinal, qualitative study (1988-2008) of the largest public health district in Georgia. STUDY DESIGN: Case study design provided deep insights into the innovation's social dynamics. Punctuated equilibrium theory helped present and make sense of the process. We identified antecedent conditions and outcomes, and we distinguished between episodes and encounters based on the disruptive effects of events. DATA COLLECTION: Twenty-five semi structured interviews with 19 decision makers and professionals, direct observations, published papers, grant proposals, technical specifications, and other written materials. PRINCIPAL FINDINGS: Strong collaboration within the district, with local community, and with external partners energized the process. Well-functioning outreach clinics made telehealth desirable. Local champions cultivated participation and generative capability, and overcame barriers through opportunistic exploitation of technological and financial options. Telehealth usage fluctuated between medical and administrative operations in response to internal needs and contextual dynamics. External agencies provided initial funding and supported later expansion. CONCLUSIONS: Extensive internal and external collaboration, and a combination of technology push and opportunistic exploitation, can enable sustainable rural telehealth innovation. US Department of health and Human Services statement by Farzad Mostashari, M. M. (2009). Aging in Place; the National Broadband Plan and Bringing Health Care Technology Home (Statement to the Senate Special Committee on Aging). HHS.gov. This presentation highlights the opportunities for home telehealth as a result of the HITECH act as well as the American Recovery and reinvestment Act of 2009. Dr. Mostashari highlights the economics of home monitoring and video consultation services.