The Third National Telemedicine & Telehealth Service Provider Showcase Conference: Advancing Telehealth Partnerships.

INTRODUCTION: As telemedicine and telehealth services are experiencing increasing rates of adoption, industry leaders and healthcare service providers are becoming increasingly focused on human resource issues encountered in the delivery of a broad range of telehealth services. To create a forum for the discussion of many interrelated elements of telehealth service industry, a national conference entitled "Telemedicine & Telehealth Service Provider Showcase" (SPS) Conference was established in 2014, and repeated in 2016 and 2017, in Arizona. These SPS Conferences include thought leaders, telehealth service providers, government administrators, and academicians from leading programs addressing service provider workforce issues. METHODS: This report summarizes the content of SPS 2017 conference, held in Phoenix, AZ, October 2-3, 2017. The topics covered at SPS 2017 include using telehealth services as a strategic asset; development of appropriate effective partnerships; direct-to-consumer initiatives; important reimbursement, legislative, and regulatory issues (i.e., Centers for Medicare & Medicaid Services [CMS] approaches, financial models, and return on investment [ROI]); marketing; evaluation and applied metrics; remote monitoring and sensors; integration with electronic health records; and overall lessons learned. RESULTS: The content of SPS 2017 is summarized in the body of this report. The SPS 2017 program evaluators included attendees, speakers, and exhibitors. The knowledge attendees gained at SPS 2017 was characterized, by all three groups, as forward-looking and practical. CONCLUSION: SPS 2017 succeeded in identifying, and focusing on, solutions for issues, challenges, and barriers impacting the rapidly expanding telehealth service segment of the healthcare industry. The growing interest in this annual SPS Conference series apparently reflects, in part, the program committee's successes in identifying practical issues and their potential solutions.

Sustaining and Expanding Telehealth: A Survey of Business Models from Selected Prominent U.S. Telehealth Centers.

INTRODUCTION: Telehealth centers across the country, including our own center, are addressing sustainability and best practice business models. We undertook this survey to explore the business models being used at other established telehealth centers. In the literature on telehealth and sustainability, there is a paucity of comparative studies as to how successful telehealth centers function. METHODS: In this study, we compared the business models of 10 successful telehealth centers. We conducted the study by interviewing key individuals at the centers, either through teleconference or telephone. RESULTS: We found that there are five general approaches to sustaining a telehealth center: grants, telehealth network membership fees, income from providing clinical services, per encounter charges, and operating as a cost center. We also found that most centers use more than one approach. CONCLUSION: We concluded that, although the first four approaches can contribute to the success of a center, telehealth centers are and should remain cost centers for their respective institutions.

The empirical foundations of telemedicine interventions for chronic disease management.

The telemedicine intervention in chronic disease management promises to involve patients in their own care, provides continuous monitoring by their healthcare providers, identifies early symptoms, and responds promptly to exacerbations in their illnesses. This review set out to establish the evidence from the available literature on the impact of telemedicine for the management of three chronic diseases: congestive heart failure, stroke, and chronic obstructive pulmonary disease. By design, the review focuses on a limited set of representative chronic diseases because of their current and increasing importance relative to their prevalence, associated morbidity, mortality, and cost. Furthermore, these three diseases are amenable to timely interventions and secondary prevention through telemonitoring. The preponderance of evidence from studies using rigorous research methods points to beneficial results from telemonitoring in its various manifestations, albeit with a few exceptions. Generally, the benefits include reductions in use of service: hospital admissions/re-admissions, length of hospital stay, and emergency department visits typically declined. It is important that there often were reductions in mortality. Few studies reported neutral or mixed findings.

Center forTelehealth and Cybermedicine Research, University of New Mexico Health Sciences Center: a model of a telehealth program within an academic medical center.

An overview of the Center for Telehealth and Cybermedicine Research at the University of New Mexico Health Sciences Center was presented along with several other national and international programs as part of the of a symposium-workshop on telehealth, "Sustaining and Realizing the Promise of Telemedicine," held at the University of Michigan Health System in Ann Arbor, MI, May 18-19, 2012 and hosted by the University of Michigan Telemedicine Resource Center and its Director, Rashid Bashshur. This article describes our Center, its business plan, and a view to the future.

Defining core issues in utilizing information technology to improve access: evaluation and research agenda.

The Department of Veterans Affairs (VA) has been at the vanguard of information technology (IT) and use of comprehensive electronic health records. Despite the widespread use of health IT in the VA, there are still a variety of key questions that need to be answered in order to maximize the utility of IT to improve patient access to quality services. This paper summarizes the potential of IT to enhance healthcare access, key gaps in current evidence linking IT and access, and methodologic challenges for related research. We also highlight four key issues to be addressed when implementing and evaluating the impact of IT interventions on improving access to quality care: 1) Understanding broader needs/perceptions of the Veteran population and their caregivers regarding use of IT to access healthcare services and related information. 2) Understanding individual provider/clinician needs/perceptions regarding use of IT for patient access to healthcare. 3) System/Organizational issues within the VA and other organizations related to the use of IT to improve access. 4) IT integration and information flow with non-VA entities. While the VA is used as an example, the issues are salient for healthcare systems that are beginning to take advantage of IT solutions.

The impact of a telehealth web-based solution on neurosurgery triage and consultation.

INTRODUCTION: To enhance the quality of neurosurgery consultations, triage, and transport decisions between a Level I trauma service neurosurgery program at the University of New Mexico Hospital and referring hospitals, a secure Health Insurance Portability and Accountability Act (HIPAA)-compliant Web-based system was developed, to which digital neurological images could be sent for review by a neurosurgeon for consultation or patient transfer. Based upon prior experience of neurosurgery, it was predicted that 25% of transfer requests would be avoided if the neurosurgeons reviewed the computerized tomography scans at the time of a transfer request. In addition, it was predicted in 25% of the case that changes in management recommendations would take place independent of the transfer decision. METHODS: The program was designed to allow referring hospitals to transmit digital images to the Web site, providing consulting doctors with additional patient information. This project analyzed the neurosurgeons' responses to questions designed to determine if transport or management decisions were altered when using this telehealth program in response to a request for consultation or transfer from a rural facility. RESULTS: Analysis of the responses of the consulting neurosurgeons revealed that, after viewing the images, 44% of the potential transfers were avoided and 44% of consulted cases resulted in management recommendation changes independent of the transfer decision. CONCLUSIONS: Use of the system resulted in improved triage and changes in transfer or management recommendations. A significant number of potential transfers were avoided, resulting in transport cost avoidance, more effective use of resources, and more appropriate use of the neurosurgery service as well as improved patient preparation.

Telehealth tools for public health, emergency, or disaster preparedness and response: a summary report.

Rapid advances in telehealth development and adoption are increasing the spectrum of information and communication technologies that can be applied not only to individual patient care but more broadly to population health as well. Participants in this breakout session were asked to address, from their diverse perspectives, a series of questions relating to the current and potential uses of telehealth applications and networks for public health and emergency/disaster preparedness and response systems. Participants identified several gaps in current understanding and research emphasis. There is a clear need for more and larger outcome studies to assess the impact and cost benefit of telehealth applications in terms of improving public health at the population and community levels. In addition, more research is needed to demonstrate the ability of telehealth tools and technologies to facilitate and extend the reach of major national clinical and public health research initiatives. Perhaps most importantly, the National Institutes of Health should develop and/or strengthen strategic partnerships with other funding agencies with overlapping or complementary interests to accelerate interdisciplinary research in this rapidly evolving but relatively understudied and complex field.

The use of virtual reality simulation of head trauma in a surgical boot camp.

Surgical "boot camps" provide excellent opportunities to enhance orientation, learning, and preparation of new surgery interns as they enter the clinical arena. This paper describes the utilization of an interactive virtual reality (VR) simulation and associated virtual patient (VP) as an additional tool for surgical boot camps. Complementing other forms of simulation, virtual patients (VPs) require less specialized equipment and can also provide a wide variety of medical scenarios. In this paper we discuss a study that measured the learning effectiveness of a real-world VP simulation used by a class of new surgery interns who operated it with a standard computer interface. The usability of the simulator as a learning tool has been demonstrated and measured. This study brings the use of VR simulation with VPs closer to wider application and integration into a training curriculum, such as a surgery intern boot camp.

Medical students learn over distance using virtual reality simulation.

INTRODUCTION: This article presents the results of a demonstration project that was designed with the goal to determine the feasibility and acceptability of medical students in using distance technology and virtual reality (VR) simulation within a problem-based learning (PBL). METHODS: This pilot project involved students from the Universities of New Mexico and Hawaii and compared (1) control groups consisting of medical students in a tutor-guided PBL session using a text-based case, (2) distance groups using the same text-based case but interacting over distance from multiple sites, (3) groups using a VR simulation scenario integrated into the case without interaction over distance, and (4) combination groups interacting over distance from multiple sites with integration of a VR simulation scenario. RESULTS: The study results suggest that it is possible to successfully conduct a PBL tutorial with medical students from two institutions with the integration VR and distributed distance interaction in combination or independently. The addition of these modalities did not interfere with learning dynamics when compared with traditional tutorial sessions. CONCLUSIONS: These findings suggest the feasibility and acceptability by students in the use of VR simulation integrated into a PBL learning session, as well as multipoint distance technologies that allowed interaction between students and tutors in different locations. The authors believe that these modalities can be applied where students and tutors from different institutions are in separate locations and can be used to support interactive experiential learning in a distributed network or on site and suggest areas for additional research.

One size doesn't fit all: bringing telehealth services to special populations.

Telehealth applications and information communication technologies can be customized and scaled to meet the healthcare service needs of a wide variety of special populations. Categorization of those special groups can be viewed from a spectrum of perspectives such as by gender, age, culture, families, communities, chronic conditions, or particular types of locations, as well as when addressing a specific or unique health need. The emergence of innovations in the use of a range of technologies and connectivity offers exciting new approaches to the integration of telehealth aimed at improving quality and continuity of care to better meet the needs of special populations.

Transforming an educational virtual reality simulation into a work of fine art.

This paper outlines user interface and interaction issues, technical considerations, and problems encountered in transforming an educational VR simulation of a reified kidney nephron into an interactive artwork appropriate for a fine arts museum.

Comparative usability studies of full vs. partial immersive virtual reality simulation for medical education and training.

Virtual reality (VR) simulation provides a means of making experiential learning reproducible and reusable. This study was designed to determine the efficiency and satisfaction components of usability. Previously, it was found that first year medical students using a VR simulation for medical education demonstrated effectiveness in learning as measured by knowledge structure improvements both with and without a head mounted display (HMD) but students using a HMD showed statistically greater improvement in knowledge structures compared to those not using a HMD. However, in this current analysis of other components of usability, there were no overall significance differences in efficiency (ease of use), nor in satisfaction, within this same group of randomized subjects comparing students using a HMD to those not using a HMD. These types of studies may be important in determining the most appropriate, cost effective VR simulation technology needed to achieve specific learning goals and objectives.

The effect of degree of immersion upon learning performance in virtual reality simulations for medical education.

Simulations are being used in education and training to enhance understanding, improve performance, and assess competence. However, it is important to measure the performance of these simulations as learning and training tools. This study examined and compared knowledge acquisition using a knowledge structure design. The subjects were first-year medical students at The University of New Mexico School of Medicine. One group used a fully immersed virtual reality (VR) environment using a head mounted display (HMD) and another group used a partially immersed (computer screen) VR environment. The study aims were to determine whether there were significant differences between the two groups as measured by changes in knowledge structure before and after the VR simulation experience. The results showed that both groups benefited from the VR simulation training as measured by the significant increased similarity to the expert knowledge network after the training experience. However, the immersed group showed a significantly higher gain than the partially immersed group. This study demonstrated a positive effect of VR simulation on learning as reflected by improvements in knowledge structure but an enhanced effect of full-immersion using a HMD vs. a screen-based VR system.

Academic health center management of chronic diseases through knowledge networks: Project ECHO.

The authors describe an innovative academic health center (AHC)-led program of health care delivery and clinical education for the management of complex, common, and chronic diseases in underserved areas, using hepatitis C virus (HCV) as a model. The program, based at the University of New Mexico School of Medicine, represents a paradigm shift in thinking and funding for the threefold mission of AHCs, moving from traditional fee-for-service models to public health funding of knowledge networks. This program, Project Extension for Community Health care Outcomes (ECHO), involves a partnership of academic medicine, public health offices, corrections departments, and rural community clinics dedicated to providing best practices and protocol-driven health care in rural areas. Telemedicine and Internet connections enable specialists in the program to comanage patients with complex diseases, using case-based knowledge networks and learning loops. Project ECHO partners (nurse practitioners, primary care physicians, physician assistants, and pharmacists) present HCV-positive patients during weekly two-hour telemedicine clinics using a standardized, case-based format that includes discussion of history, physical examination, test results, treatment complications, and psychiatric, medical, and substance abuse issues. In these case-based learning clinics, partners rapidly gain deep domain expertise in HCV as they collaborate with university specialists in hepatology, infectious disease, psychiatry, and substance abuse in comanaging their patients. Systematic monitoring of treatment outcomes is an integral aspect of the project. The authors believe this methodology will be generalizable to other complex and chronic conditions in a wide variety of underserved areas to improve disease outcomes, and it offers an opportunity for AHCs to enhance and expand their traditional mission of teaching, patient care, and research.

Virtual reality, telemedicine, web and data processing innovations in medical and psychiatric education and clinical care.

OBJECTIVE: This article highlights technology innovations in psychiatric and medical education, including applications from other fields. METHOD: The authors review the literature and poll educators and informatics faculty for novel programs relevant to psychiatric education. RESULTS: The introduction of new technologies requires skill at implementation and evaluation to assess the pros and cons. There is a significant body of literature regarding virtual reality and simulation, including assessment of outcomes, but other innovations are not well studied. CONCLUSIONS: Innovations, like other uses of technology, require collaboration between parties and integration within the educational framework of an institution.

Reification of abstract concepts to improve comprehension using interactive virtual environments and a knowledge-based design: a renal physiology model.

Several abstract concepts in medical education are difficult to teach and comprehend. In order to address this challenge, we have been applying the approach of reification of abstract concepts using interactive virtual environments and a knowledge-based design. Reification is the process of making abstract concepts and events, beyond the realm of direct human experience, concrete and accessible to teachers and learners. Entering virtual worlds and simulations not otherwise easily accessible provides an opportunity to create, study, and evaluate the emergence of knowledge and comprehension from the direct interaction of learners with otherwise complex abstract ideas and principles by bringing them to life. Using a knowledge-based design process and appropriate subject matter experts, knowledge structure methods are applied in order to prioritize, characterize important relationships, and create a concept map that can be integrated into the reified models that are subsequently developed. Applying these principles, our interdisciplinary team has been developing a reified model of the nephron into which important physiologic functions can be integrated and rendered into a three dimensional virtual environment called Flatland, a virtual environments development software tool, within which a learners can interact using off-the-shelf hardware. The nephron model can be driven dynamically by a rules-based artificial intelligence engine, applying the rules and concepts developed in conjunction with the subject matter experts. In the future, the nephron model can be used to interactively demonstrate a number of physiologic principles or a variety of pathological processes that may be difficult to teach and understand. In addition, this approach to reification can be applied to a host of other physiologic and pathological concepts in other systems. These methods will require further evaluation to determine their impact and role in learning.

Distributed interactive virtual environments for collaborative experiential learning and training independent of distance over Internet2.

Medical knowledge and skills essential for tomorrow's healthcare professionals continue to change faster than ever before creating new demands in medical education. Project TOUCH (Telehealth Outreach for Unified Community Health) has been developing methods to enhance learning by coupling innovations in medical education with advanced technology in high performance computing and next generation Internet2 embedded in virtual reality environments (VRE), artificial intelligence and experiential active learning. Simulations have been used in education and training to allow learners to make mistakes safely in lieu of real-life situations, learn from those mistakes and ultimately improve performance by subsequent avoidance of those mistakes. Distributed virtual interactive environments are used over distance to enable learning and participation in dynamic, problem-based, clinical, artificial intelligence rules-based, virtual simulations. The virtual reality patient is programmed to dynamically change over time and respond to the manipulations by the learner. Participants are fully immersed within the VRE platform using a head-mounted display and tracker system. Navigation, locomotion and handling of objects are accomplished using a joy-wand. Distribution is managed via the Internet2 Access Grid using point-to-point or multi-casting connectivity through which the participants can interact. Medical students in Hawaii and New Mexico (NM) participated collaboratively in problem solving and managing of a simulated patient with a closed head injury in VRE; dividing tasks, handing off objects, and functioning as a team. Students stated that opportunities to make mistakes and repeat actions in the VRE were extremely helpful in learning specific principles. VRE created higher performance expectations and some anxiety among VRE users. VRE orientation was adequate but students needed time to adapt and practice in order to improve efficiency. This was also demonstrated successfully between Western Australia and UNM. We successfully demonstrated the ability to fully immerse participants in a distributed virtual environment independent of distance for collaborative team interaction in medical simulation designed for education and training. The ability to make mistakes in a safe environment is well received by students and has a positive impact on their understanding, as well as memory of the principles involved in correcting those mistakes. Bringing people together as virtual teams for interactive experiential learning and collaborative training, independent of distance, provides a platform for distributed "just-in-time" training, performance assessment and credentialing. Further validation is necessary to determine the potential value of the distributed VRE in knowledge transfer, improved future performance and should entail training participants to competence in using these tools.