American Telemedicine Association 2013 Annual Meeting May 5, 2013 Austin, Texas

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1 American Telemedicine Association 2013 Annual Meeting May 5, 2013 Austin, Texas Transformations in the Delivery of Telemental Health Services: Matching Technology with Patient Need Half Day Course Coordinated by the ATA Telemental Health SIG American Telemedicine Association 1100 Connecticut Avenue NW, Suite 540 Washington, DC , fax

2 American Telemedicine Association 18th Annual International Meeting and Exposition Austin, TX Transformations in the Delivery of Telemental Health Services: Matching Technology with Patient Need Coordinated by the ATA Telemental Health SIG Half Day Course Agenda Sunday, May 5, 12:00pm - 3:00pm 12:00 12:10 Introduction/housekeeping Moderator (Carolyn and Robert) 12:10 12:30 Asynchronous/Synchronous Peter Yellowlees 12:35 12:55 POTS/cellphones Carolyn Turvey 1:00 1:30 Videophones/smartphones Gene Augusterfer et al(video) 1:35 1:40 Misc. smart phone/tablet Bart/Cassandara via Robert 1:40 1:50 BREAK (10 minutes) ***** 1:50 2:10 Laptops/Tablets Patrick O Neill (video) 2:10 2:25 Desktop applications Robert Caudill 2:25 2:45 Dedicated VTC units Jay Shore 2:45 2:50 3D imaging DVE via Robert 2:50 3:00 Future Panel

3 Transformations in the Delivery of Mental Health Services Course Faculty Robert Caudill, MD, is responsible for the administrative and clinical oversight of adult outpatient psychiatric services at the Ambulatory Care Building (ACB) at the University of Louisville School of Medicine. He completed his internship and psychiatric residency at the University of Louisville where he was a Chief Resident, President of the Psychiatric Residents Association and recipient of the John and Ruby Schwab Award for Academic Excellence. He received his board certification in psychiatry in He supervises residents and medical students during their clinical rotation in outpatient psychiatry. He lectures on a number of topics related to psychosocial rehabilitation and psychopharmacology. Along with his faculty appointment, he continues to serve as a staff psychiatrist and team leader with the local Community Mental Health Center, Seven Counties Services, Inc. Carolyn Turvey, PhD, is an Associate Professor in the Department of Psychiatry at the University of Iowa. She currently specializes in the study and treatment of depression in latelife. Her emphasis is on how functional impairment and chronic illness are risk factors for depression. She became interested in telemedicine as an innovative way to address access to care for homebound elders. She has a growing interest in using healthcare information technology to enable patients to better manage their health at home and improve coordination of care between multiple providers. Peter Yellowlees, MD, has extensive expertise in the clinical, business, policy and technical aspects of the Telemedicine industry. As a telepsychiatrist for 20 years, he has personally undertaken several thousand video consultations with patients. He developed and evaluated the first ever worldwide store-and-forward Telepsychiatry program. He has published over 200 articles and book chapters primarily on telemedicine and recently was the primary author on the American Telemedicine Association s Guidelines for Telepsychiatry. He is a Board Member of the ATA and of the California Health Information Exchange Organization and chairs the Board of HLN. Jay Shore, MD, is the Behavioral Health Portfolio Manager and SME for the Department of Defense's Telemedicine and Advanced Technology Research Center. He works on Telehealth and Mobile Mental Health projects. He is Associate Professor in the Department of Psychiatry and the School of Public Health's Centers for American Indian and Alaska Native Health, University of Denver. He leads the Native Domain for the VA Rural Health Resource Center, Western Region. Dr. Shore has been an ATA member since 2000, served on its board of directors, and is the immediate past chair for the TeleMental Health Special Interest Group.

4 Elizabeth Brooks, PhD, is an Instructor with the Colorado School of Public Health at the University of Colorado Denver and a Principal Investigator with the Veterans Rural Health Resource Center-Western Region. She has served as the Administrative Director for Telehealth with the Centers for American Indian and Alaska Native Health since She is an active participant in several telehealth research projects, She has authored a variety of papers and training materials related to telehealth economics, process and planning issues, and using videoconferencing in a culturally appropriate manner. PATRICK T. O NEILL, MD received his undergraduate and medical degrees from Creighton University in Omaha, Nebraska. He did his residency in general psychiatry at Tulane University Affiliated Hospitals. After residency, he became an Assistant Professor of Psychiatry at Tulane University School of Medicine and later was promoted to Associate Professor of Clinical Psychiatry. During this time he worked at Tulane Medical Center and Hospital as the Director of the inpatient adult psychiatry unit. Additionally, Dr. O Neill was Director of Residency Training in Adult Psychiatry at Tulane from 1987 until In 1989 he began and became the Director of the Mood Disorders Clinic at Tulane University Medical Center. A position he held until He is currently a Professor of Clinical Psychiatry in the Department of Psychiatry and Behavioral Health at Tulane University School of Medicine. He is Associate Chairman for Clinical Affairs and is Director of the Telepsychiatry Division. He has been involved in clinical drug research. This has included the areas of anxiety disorders, mood disorders, and psychotic disorders. Dr. O Neill is a Distinguished Fellow of the American Psychiatric Association and a past president of the Louisiana Psychiatric Medical Association. He is a Past President of the Association for Academic Psychiatry. He is a member of the American Telemedicine Association and its special interest group on TeleMental Health.

5 American Telemedicine Association Quality Healthcare Through Telecommunications Technology TRANSFORMATIONS IN THE DELIVERY OF TELEMENTAL HEALTH SERVICES Matching Technology with Patient Need Presentation Date: May 5, 2013

6 A continuum of platforms Asynchronous Synchronous Tablet Computer Smart Phone Laptop Desktop Computer Dedicated VTC Unit Videophones 3D imaging (not to scale) Cellphone 3D imaging Actual size Telephone POTS

7 Summary Of Technologies and Clinical Settings 1. Description of the technology in generic terms. 2. Description of the specific use to which the technology is being applied. 3. Explanation of the relative advantages of using this technology (over other alternatives) in the clinical setting being described. 4. Explanation of any relative disadvantages and limitations in terms of using this technology (over other alternatives) in the clinical setting being described. 5. Based on the speaker s experience, thoughts regarding the future prospects for uses of the technology.

8 Schedule Noon Introduction/housekeeping Asynchronous/Synchronous POTS/cellphones Videophones/smartphones Misc smart phone/tablet 1:40 1:50 BREAK (10 minutes) Laptops/Tablets Desktop applications Dedicated VTC units 3D imaging 2:50 3:00 PM Future

9 American Telemedicine Association Quality Healthcare Through Telecommunications Technology TRANSFORMATIONS IN THE DELIVERY OF TELEMENTAL HEALTH SERVICES Matching Technology with Patient Need: Asynchronous Telepsychiatry Presentation Date: May 5, 2013 Peter Yellowlees MBBS, MD.

10 Disclosures I am solely responsible for the content of this presentation. I am a co-founder of HealthLinkNow Inc.

11 A continuum of platforms Asynchronous Synchronous Tablet Computer Smart Phone Laptop Desktop Computer Dedicated VTC Unit Videophones 3D imaging not to scale Cellphone 3D imaging Actual size Telephone POTS

12 Telepsychiatry and the Patient Centered Medical Home Traditional approaches to support primary care providers retaining and managing their own patients: Direct consultations and assessments Indirect consultations phone, , secure messaging, shared EMR Addition of asynchronous consultations using video as data

13 Why Asynchronous Telepsychiatry Huge need to increase access to expertize Supports medical home and lets primary provider keep patient consultation model of care Improved curbside consult Telemedicine not used as much as expected change management/admin/scheduling Allows data to be changed/improved or focused between patient and reporting provider Increased acceptance of web visits and asynchronous medicine

14 The concept of asynchronous Telepsychiatry The same process as store and forward radiology, pathology, dermatology etc. 4 steps: 1. A clinical examination is ordered. 2. Structured data captured at the exam is sent to an expert. 3. The expert reviews the data and writes an opinion. 4. The opinion is sent to the originating provider, who may further discuss with the expert as required.

15 Why use ATP in Cross-language Settings? Original interview recorded in patients own language can be either sent to a native speaking expert, or translated prior to review. Expands mental health access for those with low English proficiency Limits the need for onsite medical interpreters and expands access to multi-lingual experts

16 Application Workflow

17 Subtitling instead of Voice-over?

18 Equipment

19 Easy Setup

20 Original Spanish History

21 Translated English History

22 Visual Studio.NET

23 Telemedicine and e-health, 17(4): , 2011.

24

25 Study 1. ATP Feasibility Store and forward feasible in 127 English speaking primary care patients with non-urgent psychiatric conditions Mood disorders Substance abuse Anxiety

26

27 Study 1. ATP Inter-rater reliability 24 Spanish speaking patients assessed 6 times each PY (Gold standard) Spanish video and English written notes with written feedback and treatment plan to referring provider SCID in Spanish by AO 2 English speaking psychiatrists using original Spanish video, English audio, and English written notes 2 Spanish speaking psychiatrists using original Spanish video and Spanish written notes.

28 Cross-Lingual Reliability Results Summary of Agreement with the Gold Standard Diagnoses (Kappa, percentage) for the two English-speaking doctors (E 1, E 2 ), two Spanish-speaking doctors (S 1, S 2 ), and SCID Kappa (Percent agreement) Frequency English Doctors Spanish Doctors SCID Diagnosis E 1 E 2 S 1 S 2 Mood Disorders a (88%) 0.65 (88%) 0.52 (83%) 0.52 (83%) 0.78 (92%) Anxiety b (79%) 0.90 (96%) 0.55 (79%) 0.73 (88%) 0.65 (83%) Substance c (96%) 1.00 (100%) 0.63 (92%) 0.63 (92%) 0.65 (96%) Psychotic Disorder/Schizophrenia (100%) 1.00 (100%) 1.00 (100%) 1.00 (100%) 1.00 (100%) a Included major Mood Disorder Due to General Medical Condition, Bipolar Disorders, Major Depressive Disorders, Dysthymic Disorder, Adjustment Disorder With Depressed Mood, Adjustment Disorder With Mixed Anxiety and Depressed Mood, Depressive Disorder NOS b Included Anxiety Disorder NOS, Panic Disorder without Agoraphobia, Generalized Anxiety Disorder, Panic Disorder with Agoraphobia, Social Phobia, Somatoform Disorder NOS, Adjustment Disorder with Anxiety, and Posttraumatic Stress Disorder c Included Alcohol Dependence, Polysubstance Dependence, Phencyclidine Dependence/Other (or Unknown) Substance Dependence, Alcohol Abuse, Cocaine Abuse, Amphetamine Abuse

29 Study 1. Cost-benefit (Butler T, Yellowlees PM)

30

31 Study 1. Summary of Findings ATP is feasible and diagnostically reliable within and across differing language groups of primary care patients, and supports the primary care medical home ATP is likely more cost-effective for consultations than either traditional inperson consultation or real-time telemedicine ATP is not being suggested for therapy. Sub-titles with automated speech recognition and translation software is ideal approach for interpretation

32 Study 2. WRAMC. Military feasibility and clinical outcomes (Lynch M, Shore J, Yellowlees PM)

33 Study 3. CCCH Second Opinion and Epic -integration into routine clinical practice scanning and uploading data response by physician connect (Yellowlees PM, Hilty D, Nesbitt T et al)

34 Next stages Language reliability paper published Study 2 is a pilot and may lead to other military applications in theater Study 3 was popular among referring providers but grant funding has finished Study 4 just commencing internal referrals at UCDHS not research UCD IRB Canadian studies commenced Jan 2013 AHRQ RO1 application under review AB 415 allows routine use and reimbursement of ATP in California. ATP is a good example of the integration of video into EMR, and the potential for this in many disciplines.

35

36 Contact Information

37 Transformations in the Delivery of Telemental Health Services Matching Technology with Patient Need: Telephone and Interactive Voice Response Carolyn L. Turvey, Ph.D. May 5 th 2013

38 Disclosures I am solely responsible for the content of this presentation. This presentation is not inteneded to represent any official position, policy, endorsement or opinion of any of the organizations with which I am involved. VETERANS HEALTH ADMINISTRATION OFFICE OF RURAL HEALTH 34

39 A continuum of platforms Asynchronous Synchronous Tablet Computer Smart Phone Laptop Desktop Computer Dedicated VTC Unit Videophones 3D imaging (not to scale) Cellphone 3D imaging Actual size Telephone POTS

40 Why the Telephone? Usability Most People Have One Most People Know How to Use One Minimal Initial Investment VETERANS HEALTH ADMINISTRATION OFFICE OF RURAL HEALTH 36

41 Why NOT the Telephone? No visual cues Poor audio quality or reliability when relying on cellular phones Almost too mobile- people find it hard not to multitask and clinicians cannot really monitor this. VETERANS HEALTH ADMINISTRATION OFFICE OF RURAL HEALTH 37

42 Another Good Reason: A Strong Evidence Base Metaanalysis by Mohr et al. 2008: Mean attrition rate = 7.6% Pretreatment Post Treatment Mean effect size d=0.81 (95% C.I ) Phone Therapy vs. Control Conditions Mean effect size d=0.26 (95% C.I ) VETERANS HEALTH ADMINISTRATION OFFICE OF RURAL HEALTH 38

43 Depression and Disease Management Trial in Rural Veterans- Aburizik et al. (under review) Mohr et al did not find phone therapy effective in a 16-week cognitive behavior therapy in 85 veterans. We conducted a 10-week combined illness management and phone based therapy on 83 veterans with a PHQ-9 score of 5 or higher Compared Combined Psychotherapy and Illness Management Illness Management Alone Usual Care VETERANS HEALTH ADMINISTRATION OFFICE OF RURAL HEALTH 39

44 Results p<0.01 VETERANS HEALTH ADMINISTRATION OFFICE OF RURAL HEALTH 40

45 Lessons Learned about how to do Therapy by Phone Schedule meetings for the same time each week. If not too inconvenient and possible, try to use land lines Combine with in-person meetings Educate patients about privacy issues and multitasking Educate patients who are self-designated as not phone people. VETERANS HEALTH ADMINISTRATION OFFICE OF RURAL HEALTH 41

46 Pilot Study of Validity of IVR Administered PHQ-9 Examine the validity of administering the 9- item Patient Health Questionnaire using interactive voice response technology when compared to mailed/pencil and paper administration Construct validity- Factor Analysis Internal Consistency- Chronbach s Alpha Agreement Intraclass Correlation Coefficient, not correlation Kappa VETERANS HEALTH ADMINISTRATION OFFICE OF RURAL HEALTH 42

47 Common Perception When assessments occur on technology, respondents are more candid because they feel their responses are more anonymous. VETERANS HEALTH ADMINISTRATION OFFICE OF RURAL HEALTH 43

48 Psychological Assessment via the Internet- Vallejo, 2007 Administered the General Health Questionnaire and the SCL-90 via internet and via pencil and paper in 186 psychology students Factor analyses and Internal Consistency were comparable for both the SCL -90 and the GHQ Paper and pencil means were significantly higher than online means for all but two subscales in the SCL % of variance in score responses could be due to administration VETERANS HEALTH ADMINISTRATION OFFICE OF RURAL HEALTH 44

49 Randomized Trial of Mail, Internet, and Interactive Voice Response Telephone Administration of Surveys- Rodriguez et al ,198 respondents were randomly assigned to complete an abbreviated version of the Ambulatory Care Experiences Survey Internet and web surveys did not differ in item level or composite level results. In IVR most item-level and composite level results were significantly lower. VETERANS HEALTH ADMINISTRATION OFFICE OF RURAL HEALTH 45

50 What is satisficing and why do we care? Krosnick, 1991 Incomplete or biased information retrieval and/or information integration No information retrieval Leads to 1) choosing the first response alternative that seems reasonable 2) saying don t know instead of discerning between alternate responses 3) randomly choosing responses VETERANS HEALTH ADMINISTRATION OFFICE OF RURAL HEALTH 46

51 Current Pilot Study- Methods 51 Veterans participating in a larger RCT of depression in heart failure completed both an IVR and a mailed version of the 9-item Patient Health Questionnaire. This is a common measure of depression in primary care. IVR reponse choices were arranged to try to counter satisficing. VETERANS HEALTH ADMINISTRATION OFFICE OF RURAL HEALTH 47

52 Revised Response Choice Format Feeling down, depressed, or hopeless Not at all Several Days More than half the days Nearly every day Feeling down, depressed, or hopeless Nearly Every Day More than half the days Several Days Not at all VETERANS HEALTH ADMINISTRATION OFFICE OF RURAL HEALTH 48

53 Initial Statistics Paper and Pencil Mean (sd) 4.1 (4.5) Minimum 0 Maximum 18 Chronbach s Alpha 0.82 IVR Mean (sd) 2.8 (3.1) Minimum 0 Maximum 14 Chronbach s Alpha 0.76 VETERANS HEALTH ADMINISTRATION OFFICE OF RURAL HEALTH 49

54 Results of Quartimax Factor Analysis PHQ-9 Item Pencil and Paper Little interest or pleasure Feeling down, depressed, or hopeless Trouble falling or staying asleep, sleeping too much Feeling tired or having little energy Poor appetite or overeating Feelings of guilt or worthlessness Trouble concentrating on things, newspaper TV Feeling restless or moving more slowly Better off dead, thoughts of hurting oneself % total variance explained 43% 36% IVR VETERANS HEALTH ADMINISTRATION OFFICE OF RURAL HEALTH 50

55 Item means and Agreement Total Scale 10+ Threshold Total Scale 5+ Threshold VETERANS HEALTH ADMINISTRATION OFFICE OF RURAL HEALTH Pencil and Paper IVR Kappa Value Little Interest or Pleasure Low 0.58 Mild Feeling down, depressed, or hopeless Incalculable Trouble Falling or Staying Asleep Feeling Tired, no energy Poor appetite or overeating Feeling bad about yourself Incalculable Trouble concentrating on things Incalculable Moving slowly or fidgety/restless Incalculable Better off dead or hurting oneself

56 Conclusions IVR administered PHQ-9 is assessing the same construct of depression as the pencil-and-paper method Using the full scale score, intraclass correlation coefficient estimates of agreement are acceptable Kappa coefficients using the 10 or higher threshold are unacceptable. A 5 or higher is preferred VETERANS HEALTH ADMINISTRATION OFFICE OF RURAL HEALTH 52

57 Limitations Pilot study and needs to be tested on a larger sample. Patients were not depressed so the full range of the scale was not used. Formal administration and counter balancing methods were not used. VETERANS HEALTH ADMINISTRATION OFFICE OF RURAL HEALTH 53

58 Laptop Technology in Support of Telemental Health One Department of Psychiatry s Experience

59 Patrick O Neill, MD Professor of Clinical Psychiatry Associate Chair for Clinical Affairs Director, Division of TelePsychiatry Tulane University School of Medicine

60 Laptops at Tulane Department of Psychiatry currently does over 170 hours of direct patient care to rural Behavioral Health Clinics in Louisiana. Includes both Adults and Children, 7 faculty and 5 residents each currently spend from 4-32 hours/week in TelePsych activities. Daily equipment used currently are 10 Polycom HDX 4000 desktop units. Expectation for growth/expansion.

61 Laptops at Tulane New Orleans has frequent tropical storms and named Hurricanes. Since Katrina in 2005 the city has been evacuated twice secondary to dangerous storms with flooding and high winds. Most Telepsychiatry clinical sites are in areas that were not evacuated and not negatively affected by storms.

62 Laptops at Tulane Department installed Polycom Telepresence m100 or PVX software on laptops purchased to support the faculty s departmental activities. This software allows connection with patient care sites using the internet via encrypted connections. Upgraded with external webcams.

63 Laptops at Tulane These units are currently being used mainly as backup for Polycom desktop units. In event of prolonged hurricane evacuation, plan is to use these units to provide ongoing clinical activities to patient sites that are open. Allows for minimally disrupted patient-care. Allows for continued revenue for the individual faculty member and department.

64 Laptops at Tulane Advantage include: Obvious mobility of the platform to provide services. Ensures encryption and allows for HIPAA compliant use of public internet. Standardization of configuration to improve ability to provide service and maintenance. Scalable as services demands change.

65 Disadvantages: Laptops at Tulane Need for policy to ensure HIPAA compliance at sites away from home facilities. Assumes availability of sufficient/secure internet connectivity to support clinical functions. Size of the screen can be a clinical issue (Tardive/tremor/crying). May need to use headset to avoid feedback issues.

66 Disadvantages cont. Laptops at Tulane Cost of software and necessary peripheral hardware Departmental and School policies preclude the use of Skype and other free video conferencing systems. Difficult to do concurrent documentation to a EHR on a small screen. Lack of comparative studies looking specifically at laptop usage.

67 Laptops at Tulane Future prospects Over the short term growth of the use of personal computer options in Telemedicine will continue, driven by costs and acceptance. Numbers of new computers bought has show a significant increase in percentage of laptops bought versus desktop form factor. Many clinicians now use laptops as their primary or only computer. The growth of laptop use in Telepsychiatry will be replaced in the Longer term by tablet or other mobile computer based systems.

68 Assistant Professor Director, Ambulatory Care Building Psychiatry Clinic Director, Telemedicine and Information Technology Programs University of Louisville Department of Psychiatry. American Telemedicine Association Quality Healthcare Through Telecommunications Technology Desktop And Other PC Based Internet Videoteleconferencing Platforms Robert Caudill, M.D. Assistant Professor Director, Ambulatory Care Building Psychiatry Clinic Director, Telemedicine and Information Technology Programs University of Louisville Department of Psychiatry. Presentation Date: May 5, 2013

69 A continuum of platforms Asynchronous Synchronous Tablet Computer Smart Phone Laptop Desktop Computer Dedicated VTC Unit Videophones 3D imaging not to scale Cellphone 3D imaging Actual size Telephone POTS

70 Disclosure The views and opinions expressed in this presentation are my own and do not necessarily reflect the official policy or position of any one else, yet. No pharmaceutical or commercial interests were involved in the production of this presentation. No animals were harmed in the making of this PowerPoint.

71 Description Of The Technology In Generic Terms telemental health services delivered in real-time using internet-based videoconferencing technologies through personal computers and mobile devices. Other (not covered today): texting, , chatting, social network sites, online coaching or other non-mental health services.

72 Subtypes

73 Subtypes 1. Secure 2. Non-secured 1. IP (internet protocol) addressable 2. Non-IP addressable (proprietary) 1. Application driven 2. Internet based.

74 Description of the specific use to which the technology is being applied. 1. Delivery of clinical services to rural Community Mental Health Centers. 2. Far sites have a variety of platform with which to receive incoming clinician presence 3. Origination sites (in this example, university based, faculty member, psychiatrists) using PC based platform with webcam and 20 inch monitors usually. 4. Evaluations and medication management primarily.

75 Relative Advantages Of Desktop-PC- Based Technology (Over Other Alternatives) In a Clinical Setting 1. Lower cost per unit. 2. More units available (as a result of lower cost) 3. Convenience for clinicians (work from own office on own PC) 4. Reduced parallax gaze angle smaller 5. Ergonomics easily combine with use of electronic medical record.

76 Relative disadvantages and limitations in use of this technology (over other alternatives) in the clinical setting being described. 1. Inferior to VTC in teaching mode. 2. Clinician loses some sense of virtual presence. 3. IT support crucial but more variable. VTC units often associated with small, specialized group of technical support. PC based more likely to be serviced by general IT technicians with potentially less familiarity with the operation. 4. Convenience

77 Thoughts Regarding The Future Prospects For Uses Of 1. Can only expand to a degree 2. However, future of desktop PC as we know it may be under some uncertainty. 3. Potential lies increasingly with technology capabilities at receiving end. 4. Need for inexpensive or else web-based, HIPAA compliant portals through which this work can be done obviating the need specific programs to be loaded onto PC.

78 Contact Information

79 American Telemedicine Association Quality Healthcare Through Telecommunications Technology TRANSFORMATIONS IN THE DELIVERY OF TELEMENTAL HEALTH SERVICES Matching Technology with Patient Need: Dedicated VTC Units Presentation Date: May 5, 2013 Jay Shore MD, MPH

80 Disclosures I am solely responsible for the content of this presentation. This presentation is not intended to represent any official position, policy, endorsement or opinion of any of the organizations with which I am involved.

81 A continuum of platforms Asynchronous Synchronous Tablet Computer Smart Phone Laptop Desktop Computer Dedicated VTC Unit Videophones 3D imaging (not to scale) Cellphone 3D imaging Actual size Telephone POTS

82 What is Dedicated VTC Units?

83 BRIEF HISTORY OF VTC

84 Nebraska Telepsychiatry 1959,University of Nebraska used twoway closed-circuit microwave television system between the Nebraska Psychiatric Institute and Norfolk State Hospital in Nebraska providing consultations, education, training, and research.

85 Photos from UNMC Archives, Special Collections Department, McGoogan Library of Medicine, University of Nebraska Medical Center, Omaha, Nebraska Dr Reba Benschoter of the University of Nebraska, Telemedicine advocate 1960s Drs. Benschoter and Dr. Wittson in Univ. of Nebraska's telemedicine studios Psychiatric lectures via television with the Nebraska Psychiatric Institute, 1956 Dr. Affleck and an unidentified technician evaluate telemedicine equipment, 1961 Group telepsychiatry in progress using twoway video/audio links,1961 The Institute's recording facilities. Technician operating an early videotape recorder. Dr Menolascino participates in a video teleconsultation, 1966

86 STARPAHC

87 History of Telemedicine Been around since 1960s Programs ended when grant ended Technology revolution in 1990s made current rebirth possible Currently in critical phase of development of the field Current Health System issues (cost, quality, access, provider shortages) Technology convergence 1970s microprocessors integration of technology in medicine Parallel societal revolution in technology

88 Current Evidence supporting Videoconferencing Growing body of evidence Satisfaction Diversity of application Outcomes Economics

89

90 Clinical Impacts Therapeutic distance Confidentiality Flow of clinical process Rapport Alliance issues Observing ego

91 Strengths of Dedicated VTC Units 1. Larger images (clinical implications) 2. Better for groups 3. More likely to be able to control camera remotely 4. Often with dedicated room or set-up Limitations of Dedicated VTC Units 1. Cost 2. Mobility 3. Technical infrastructure

92 When to consider using dedicated VTC > desktop/platform Groups Clinical and hospital settings Clinical need to increase virtual presence or detect subtle signs and symptoms

93 Contact Information Jay H. Shore, MD, MPH Associate Professor Centers American Indian and Alaska Native Health University of Colorado Anschutz Medical Campus Mail Stop F800, East 17 th Avenue Aurora, CO Phone: , Fax:

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