CHAPTER SEVEN

E-HEALTH DOMAINS

Surveying the E-Health Landscape: Cases and Applications

Pam Forducey, Kawaljeet Kaur, Cynthia Scheideman-Miller, Joseph Tan

I. Learning Objectives

II. Introduction

III. E-Medical or Direct Patient Care Services

A. Tele-Ultrasound in Australia

B. E-Home Care Services at the University of Tennessee

C. Other E-Home Care, E-Counseling, and E-Disease Management Applications

IV. E-Learning and Tele-Education Services

A. Medical and Health Information Web Sites

B. Virtual Communities

C. Web-Based Databases

D. E-Learning

V. E-Administrative and Support Services

A. E-Prescription

B. Electronic Health Records

C. E-Supply Ordering, E-Claims, and E-Remittance

D. E-Decision Support

E. E-Work

VI. TeleRehab™ at INTEGRIS Jim Thorpe Rehabilitation Center

VII. Conclusion

VIII. Chapter Questions

IX. References

X. E-Speech Therapy for Children in a Rural Oklahoma School Case

Learning Objectives

1. Identify various models and modalities of the evolving e-health care system, including e-commerce, e-health, telemedicine, telehealth, e-home care (or telecare)
2. Illustrate the use of e-medicine, e-rehabilitation, e-home care, and e-disease management technologies and their significance for the future of e-health care development
3. Conceptualize e-learning and tele-educational models for intentionally affecting user (patient and provider) behavioral changes
4. Know the various facets of e-administrative and support services to which information technology and e-technologies are being applied
5. Understand e-rehabilitation as an application to illustrate a specific e-health domain

Introduction

Fifty-nine percent of Americans believe that our current health care system requires a major restructuring. This statistic is not surprising, given the stark reality that the annual health budget of the United States is now estimated at over a trillion dollars, while approximately 45 million Americans do not have health insurance.

Due to escalating costs of health care delivery, the Center for Medicare and Medicaid Services—a U.S. government agency—has imposed financial restrictions such as managed care and a prospective payment system (PPS). PPS essentially provides predetermined fixed-price payment rates for specific categories of illnesses or diagnostic related groups (DRGs). Because the PPS depended extensively on the use of averages to calculate reimbursements and payments to the health facility treating an insured patient, the system does not consider the severity of the patient's illness nor are the facilities being reimbursed if actual payments exceed those PPS-calculated payments. Moreover the lack of predictability of such payments, increased regulations due to the federal deficit reduction initiations and other factors such as structural and educational payment changes make it difficult for hospitals and other health agencies to rely on traditional guarantees of payments for their services. PPS therefore mandates that health care facilities reexamine resource utilization and organizational effectiveness. Simply put, there is a serious and urgent need for a reevaluation of our health care system and exploration of alternative approaches to health care financing and delivery if we are to contain U.S. health care costs and prevent their further acceleration (Woods, 2001).

In Canada, the situation is perhaps equally serious; for example, hundreds of residents in the small town of Windsor do not have a family physician and rely on walk-in clinics. The Canadian shortage of doctors and nurses is causing delays and longer waiting times even for prescheduled surgical interventions, as well as an increasing number of bed closures, causing a continual shifting of services from primary care to secondary and tertiary care facilities. Health care costs for all parties including local government, providers and consumers alike have continued to rise in every Canadian province because of federal budgetary restraints, the aging population, and increasing dollars set aside for national security, public preparedness, and surveillance to defend against terrorist activities. Given the current unlimited wants and demands from all directions but only very limited health care resources to spare, it is critical for us to examine where-about (the domains) and how specifically (the applications) emerging e-technologies can maintain, even improve, the health status and future well-being of those living in countries such as the U.S. and Canada.

Emerging technologies and accompanying processes are being incorporated into mainstream health care on a daily basis. The expanding field of information and communication technology (ICT) is producing applications in e-commerce, e-health, telemedicine, telehealth, and e-home care (or telecare). E-commerce refers to the use of ICT to conduct business transactions, irrespective of physical or geographic boundaries. E-health, telemedicine, and telehealth all entail the application of the same principles to the health care field—that is, facilitating communications, collaborations, and e-commerce between health care providers and consumers without the limitations of time and location that are imposed by the traditional health care system. E-home care (telecare) is the application of the same technology for patient care, especially tele–home health care services. Despite fine semantic differences, many of these terms are sometimes used interchangeably.

There are two primary types of e-commerce transactions in health care: business-to-business (B2B) and business-to-consumer (B2C) transactions. B2B transactions are between the business entities, including the vendors, hospitals, insurance agencies, physicians' offices, and regulatory agencies. Consumers are not directly involved in these transactions. B2C transactions are between businesses or providers on the one hand and consumers on the other hand. In the context of e-health systems, these transactions may also be referred to as patient-to-provider (P2P) transactions. Another rapidly growing cluster of e-health care activities involves consumer-to-consumer (C2C) applications that have contributed to the creation of virtual communities, which have great potential to empower individuals and the public (Svensson, 2003).

A majority of e-health interactions use the World Wide Web as the infrastructure for business activities. The Web has the advantage of universal client software (Web browser) and a preexisting platform (the Internet). For e-commerce activities, eXtensible Markup Language (XML) provides a functional platform for transactional data exchange. The other major infrastructure used in e-health commerce systems is electronic data interchange (EDI), the exchange of data among organizations in a structured format (explained in Chapter One). However, due to high cost, the need for proprietary software, and trading volume requirements, EDI is rapidly declining in popularity, making way for Web-based, XML-functional e-health systems (Aggarwal and Travers, 2001). The theoretical perspectives for understanding and differentiating among the various e-commerce models discussed here have been explored to some extent in Chapter Three. Our focus in this chapter is on applications of e-health models and technologies.

Health care is a knowledge- and information-intensive industry, and e-health is changing health care. E-health has diverse applications, some of which have been studied and used extensively (for example, teleradiology, as discussed in the preceding chapter), while others are still in the experimental phase (for example, virtual reality which is discussed in Chapter Sixteen). Most e-health applications fit into three broad categories based on primary functions: (1) e-medical and direct patient care, (2) e-learning and tele-educational services, and (3) e-administrative and support services. This chapter is organized according to these three major service clusters. Once this background is in place, we examine the services performed at INTEGRIS Jim Thorpe Rehabilitation Center as a case study of e-health service domains.

E-Medical or Direct Patient Care Services

E-medical or direct patient care services involve the administration of direct patient care using ICT. These applications include the following:

• E-medicine, including e-diagnostic imaging
• E-home care and telemonitoring
• E-counseling
• E-disease management

E-medicine (or telemedicine) is the delivery of general and specialty e-clinical services to remote areas, using ICT and e-networking (see Chapter Six). In recent years, telemedicine has branched into various specialty disciplines that include the transmission of visual media in fields like teleradiology, teledermatology, telepathology, tele-ophthalmology, telesurgery, and robotics, as well as direct patient care and rehabilitation. Chapter Eight focuses on applications of e-medicine for both developed countries such as Canada and developing regions such as sub-Saharan Africa; Chapter Ten presents future developments in teleradiology; and Chapter Sixteen discusses virtual reality applications such as telesurgery and robotics.

Although it is increasing in popularity, e-medicine faces several challenges. First, e-medicine can require expensive infrastructure, making it difficult for underdeveloped or developing countries to adopt the technology. In addition, this same technology is not very useful for island states like Singapore because of its extent of urbanization, unless these city-states are used as centers for providing specialty e-medical care to less developed neighboring countries that have many rural settings. For example, Singapore could act as a hub, providing teleradiological services to other South-East Asian countries such as Malaysia, Vietnam, Cambodia, Thailand, Indonesia and the Philippines.

To be successful in teleradiology, however, as in any marketplace, a critical volume of services must be rendered in order to achieve cost-effectiveness and economies of scale. Difficulties also could arise due to different cultural and economic standards in neighboring countries; lack of equipment compatibility; uncertainty or lack of political will to participate in the program; socioeconomic complexities; cultural differences and regional relationships; legal procedures and policies regarding reimbursement for services; or currency valuation and monetary exchange policies, among other factors. Cooperation at national and international levels would be needed to realize such a vision. An official ceremony at which agreements of understanding are signed by the different heads of the countries is likely to be warranted, in order to promote sustained and meaningful collaborations among the countries.

E-medicine becomes truly cost-effective when it is planned and designed, just as with e-business, to become an integral part of the country's telecommunications and information technology infrastructure. Accordingly, e-medicine can then be available to serve a large geographical area in many health care specialty domains—for example, teleradiology and e-rehabilitation—where the costs of hiring specialists in these specific domain areas are prohibitive. Although e-medicine faces the problem of lack of physicality and direct human interaction, it is becoming increasingly popular as a means of providing care to the medically underserved and to areas experiencing health care shortages. Most e-medicine programs started as federally funded pilot projects to demonstrate the efficacy, viability, and feasibility of telemedicine networks. Concerted action is needed at both national and international levels to develop standards in order to reach network compatibility and build ethical frameworks (Stanberry, 2000; Terry, 2001; Mitchell, 2000).

E-medicine involves several components, all of which work together to create a strong consumer-oriented environment. Teleconsulting refers to the use of e-medical services by the patient to consult with a health care provider. Teleconferencing is the use of e-medicine by clinicians to confer with one another about a patient. Telereporting is the transmission of information about a patient to a remote site. Telemonitoring refers to monitoring a patient remotely by collecting patient information and analyzing it at a remote site.

Potential benefits of telemedicine include fewer office visits for patients; improved care for the elderly and people living in remote areas; convenience; and cost reduction. The disadvantages include missing the benefits of direct physical interaction; and costs associated with technology infrastructure setup. Challenges in implementing telemedicine include lack of consistency and quality in video links; patient confidentiality issues; need for support from management; and need for motivation on the part of patients and providers to try a new health care delivery model.

Tele-Ultrasound in Australia

Diagnostic ultrasound is an important component of health care services that is in great demand. In isolated and rural areas, however, a lack of local clinical expertise often limits its use. The Commonwealth Scientific and Industrial Research Organization's Telecommunications and Industrial Physics Center at Macquarie University in Sydney, Australia, has developed a high-performance, low-bandwidth, real-time tele-ultrasound device. This device transmits live ultrasound images to an expert consultant while the examination is in progress. The system operates under the control of the expert at the receiving end, which minimizes distractions from the ultrasound operator at the transmitting end and enables the expert to set transmission parameters.

Tele-ultrasound operates satisfactorily at a transmission rate of 128 kilobits per second because it uses compression technology with a “region of interest” within which the image is transmitted at high resolution and at relatively high frame rates. The remainder of the image is transmitted at a relatively low frame rate. The position and size of the region of interest is controlled by the consultant at the receiving end. The tele-ultrasound technique is compatible with all types of ultrasound equipment and is suitable for both color and gray-scale images (Tele-Health Applications, 2003).

E-Home Care Services at the University of Tennessee

E-medicine does not just include direct interaction through video modalities; it is increasingly being used for telemonitoring of patients in e-home care applications. For example, remote heart monitoring through halter devices is being used at several places in Europe; using devices such as mobile phones, data are transmitted in real time to the base station for analysis. Projects are also under way to develop sensing and storage technologies, which permit installation of simple devices in the home that link into a network for remote monitoring by health care professionals; medical interventions take place only when needed.

The telephone is the oldest tool for e-home care services. For example, University of Tennessee Home Care Services, along with the University of Tennessee Medical Center Telemedicine Network at Knoxville started providing e-home care in April 1998 as part of a federally funded demonstration project. The system uses a video camera, a video monitor, a speakerphone, and an electronic interface with the regular analog phone line at the patient's home. In addition, handheld digital monitoring devices such as glucometers, sphygmomanometers, pulse oximetry, spirometers, scales, and thermometers are used to check the patient's situation.

With these e-home technologies, nurses can now “see” their patients, evaluate medication compliance, read home monitors, and even check the dose in an insulin syringe. Skin tones and wounds can be assessed remotely. Based on the travel costs saved, the investment per home has been shown to be equivalent to the cost of about thirty home care visits. More intriguing is that the nurses were proficient with the system within just one week of training. It is conceivable that where there is a shortage of qualified nurses and doctors, paramedics and home caregivers can be trained to substitute for professional nurses, and residents and foreign doctors can substitute for licensed physicians. This will only work if the resulting home health care services are legal in the proposed jurisdiction.

In a study by Dimmick, Mustaleski, Burgiss, and Welsh (2000), nurses and some primary care physicians made about 444 tele–home care visits for conditions ranging from congestive heart failure to diabetes. The system had the benefit of low capital equipment cost and ease of use. Typically, the home care patient was called once or twice per week, depending on the patient's condition. Both the patient and the care-giver were trained in the use of the videophone and other equipment. Depending on the patient's hearing capabilities, the patient used either the speakerphone or the phone receiver. Telehealth has progressed considerably over the years (Durtschi, 2001), and as telephone technologies advance, new means of connecting with patients to enhance e-home care will naturally emerge. More recently, the concept of smart homes for the elderly and frail has brought together architects, building contractors, electrical and mechanical engineers, health care professionals and workers, owners of security management companies, and others to adapt existing houses to serve the needs of the e-home care industry. This topic is discussed further in Chapter Nine.

Other E-Home Care, E-Counseling, and E-Disease Management Applications

Studies similar to Dimmick, Mustaleski, Burgiss, and Welsh's have been conducted elsewhere. In the United Kingdom, researchers explored the management of chronic obstructive pulmonary disease through interactive video. The e-care providers were able to complete charts, assess oxygen saturation, evaluate peak expiratory flow rates, and measure temperature and pulse, all through interactive videos. The Harvard Telepsychiatry Project investigated the use of videophones to provide telepsychiatric services in home health settings, with encouraging results. In North Carolina, the use of e-home care resulted in fewer long-term care placements and a reduction in the number of emergency room visits and in-patient hospitalizations (Dimmick, Mustaleski, Burgiss, and Welsh, 2000).

E-counseling (or on-line counseling) is another telemedicine modality that is gaining popularity as a means of reaching teenagers and other target populations who would not otherwise seek help. According to Xinhua News Agency, an on-line suicide intervention center was recently launched in China that connects patients with fifty psychiatrists from forty-four hospitals throughout the country. The Beijing Suicide Research and Prevention Center will provide services to a select population of 16 million Chinese who have various mental disorders. A recent survey in China revealed that about 90 percent of people with depression received no medical treatment, and only about 20 percent of those who sought treatment were treated appropriately. If anonymity and confidentiality can be ensured, the benefits of having a Web-based e-counseling service to serve these high-risk population groups far outweigh the costs of maintaining the Web site.

E-disease management is the last specialty domain of telemedicine that we will cover in this discussion. The concept of e-disease management is based on the fact that patients with chronic illnesses account for 70 percent or more of health care costs. In theory, therefore, an efficient e-disease management program could substantially reduce medical and administrative costs, resulting in trickle-down benefits for both patients and payers. E-patients who are interested in self-care can join a specific management program and report their vital readings via the Internet or phone on a daily basis. A nurse checks the readings regularly and alerts the patient if he or she notices any abnormality or change. Aggarwal and Travers (2001) argue that advertising, sponsorship, or subscription fees can generally be used to support or sustain these programs.

E-disease management systems range from sophisticated Web-based systems to text reminders on cell phones to networked hospital and community-based programs. Health Buddy, created by Health Hero Network in Mountain View, California, is a Web-based e-disease management tool that is being used for congestive heart failure (CHF) management. Health Buddy is a book-sized computer that asks the patient's weight and blood pressure. When directed by a nurse, it also has the capacity to ask the patient a set of questions (for example, what, when, and how various symptoms of the illnesses become aggravated or relieved). Such systems hold the promise of decreasing treatment costs, but they usually require costly, hard-wired computer systems that may be slow to change with changes in treatment protocols. Proponents of these e-disease management systems include vendors, application service providers (software vendors who also sometimes provide health computing consulting), and Web site developers. A conclusive business and clinical case for such e-disease management systems is still to be made (Joch, 2000).

LifeMasters is an example of a cost-saving e-disease management program for CHF patients. A controlled study revealed that the use of LifeMasters had resulted in savings of approximately $950 per month for CHF patients, with a 66-percent reduction in emergency room visits, compared with the control group. The referral process for patients wanting to be physically seen by their care providers involves about ten to fifteen steps, with the cost adding up to about $40 per referral. Many, if not all, of these steps can be bypassed if providers and patients are willing to go the electronic route (Goran and Standford, 2001).

E-LEARNING AND TELE-EDUCATION SERVICES

Electronic media and Web-based systems are increasingly being used for e-learning and tele-educational purposes, for patients as well as for health care professionals. Applications of e-health education include the following:

• Medical information Web sites
• Virtual communities
• Web-based databases
• E-learning

Medical and Health Information Web Sites

Access to medical information via the Internet has the potential to accelerate the transformation of the patient-physician relationship from that of physician authority ministering advice and treatment to that of shared decision making between the patient and the physician (Winker and others, 2000). According to analysis conducted by Mediametrix (mediametrix.com), the most frequently visited health sites on the Web include Intellihealth.com (Johns Hopkins), Mayohealth.org, and OnHealth.com. These sites provide health-related news and information in an interactive way (Cochrane, 1995). A survey by Harris Interactive (2003) indicates that the number of adults looking for health information on-line has been steadily increasing: 27 percent in 1998, 34 percent in 1999, 47 percent in 2001, and 53 percent in 2002. E-consumers with higher incomes and college or postgraduate degrees are more likely to use the Internet to find health information than their lower-paid or less educated counterparts. Hirsch (2000) argues that a better-informed patient will result in more time for the development of the doctor-patient relationship and thereby improve therapeutic compliance and outcome. E-physicians are also using Web-based information—for example, the “Harrison Online” Web site, where the information is provided mostly in the form of e-books, which are updated much more frequently than traditional paper publications (Selsky and others, 2001). Other sites such as “MDConsult” and “StatReference” also have full-text reference books with complete search capabilities. Most of these sites also contain practice guidelines and drug information or links to other sites that contain such information.

Virtual Communities

The creation of virtual on-line communities (e-communities) (see the case in Chapter Fifteen), so that people with similar interests could chat with one another, was one of the earliest uses of the Internet. This type of communication has become increasingly popular in health care, even among senior groups, minorities, and those living in rural and remote areas. Virtual communities serve as on-line support groups for both e-patients and e-caregivers. Numerous e-health companies are also promoting the concept of virtual communities as part of e-disease management programs. These communities provide consumers with general information, information about medical research on particular diseases, and information on available products and services specific to these diseases, as well as psychological support from affected patients facing the same condition. In addition, these communities provide a locus for patient advocacy.

Paradoxically, the patients who benefit the most from such communities are the ones with rare diseases, because virtual communities allow them to conveniently communicate with other people experiencing the same condition. For such patients, being a member of a virtual community can provide tremendous positive psychological effect (Patsos, 2001). A good example of such a support group is Alzheimer's Caregiver Support Online (2003). This community is the culmination of teamwork between the state of Florida's Department of Elders Affairs and the University of Florida's Center for Research on Telehealth and Healthcare Communications. The site presents scheduled expert presentations on topics relating to dementia care and provides a message board; a chat room for the users (this serves as a support group); and an e-library (electronic or digital library) that provides information on dementia, caregiving techniques, and research and developments in the field. The site also provides links to other state, federal, and community resources for dementia caregivers. The virtual class presentations are interactive and hosted by the staff, and they can be recorded so that viewers have the flexibility to view them at their convenience.

Web-Based Databases

As biological databases expand as a result of new research in genetics and other medical fields, a huge market is emerging in portal-based dissemination of biological content for the process of drug discovery testing, research and development. OVID, PubMed, and Medline are databases that store information in the form of journal articles, available on a subscription basis or otherwise (Jadad and Gagliardi, 1998; Razvi, 2000). Some of these databases include the Cumulative Index to Nursing and Allied Health Literature (CINAHL); Health and Psychosocial Instruments (HAPI); the Educational Resources Information Center (ERIC); Cancer Literature Online (CANCERLIT); AIDS Information Online (AIDSLINE); Online Mendelian Inheritance in Man (OMIM); and the Structure, Taxonomy, and Genome Databases.

In recent years, discussions have been ongoing to facilitate research and education; Internet2 is a consortium led by two hundred universities, in partnership with the government and industry, to develop advanced Internet technology and applications. It is a project of the University Corporation for Advanced Internet Development. Internet2 provides a leading-edge network capability for the national research community by linking research databases. Aside from increased speed and capacity compared to what are currently available in the Internet, Internet2 is designed to be reserved primarily for use in high-powered computing related research and development.

E-Learning

Although Web-based education is becoming commonplace in universities and colleges, its acceptance in the health care setting is still lagging, more in Canada than in the United States. Health care curriculum is different from that of most other fields, but e-learning has its place even in this specific context. Health care professionals can now attend classes, group meetings, workshops, conferences, and educational events online. With the expansion of voice and video capabilities, face-to-face interaction and learning are becoming easier (Hirsch, 2000; Herrin, 2001; Neuhauser, 2000).

In health care, e-learning has been primarily used for continuing medical education courses for professionals (e-CME) and administrative training in areas such as compliance. Many companies and physician portals provide such courses. The major ones are Healthstream, Physicians Online, Massachusetts General Hospital, Johns Hopkins, Mayo Clinic, and WebMD. These programs range from pure Web-based programs to hybrid Internet and compact disc (CD) modules that combine the record-keeping capabilities of the Internet with the bandwidth of CD media as data to be shared or integrated are either on the CD or on the Internet (Anderson and Stenzel, 2001).

E-learning also involves multimedia training systems and simulations. Computer simulation modeling has advanced considerably over the past twenty years and is now widely employed in various teaching settings. One example of a learning simulation is CathSim Intravenous Training System, which is used by nurses to learn how to perform intravenous annulations before they do the procedure on a real patient. CathSim is a computer-based system that has interactive multimedia instructions and a tactile feedback device. Feedback is provided on the final outcome as well as on the progression of the procedure. This simulation-based training improves nurses' experience and comfort level with doing the procedure, with resultant decrease in the rates of complications in the patients after intravenous annulations (Chang, Chung, and Wong, 2002). Surgeons at the University of Kentucky are developing computer-based simulators to train other surgeons to perform minimally invasive procedures. The simulators are based on the 3-D and other virtual reality technology previously used only in flight simulators.

Another example of an e-learning application would be the use of computer software in an easy-to-use educational module to help pregnant women who stopped smoking during pregnancy to avoid postpartum relapse. Such patients could be kept abreast of the latest research on the effect of smoking on childbirth and on their own health following childbirth. They could also be educated on strategies for overcoming the temptation to relapse.

The key to effective e-learning software is the design of the interface, because, to the user, the interface is simultaneously the computer, the counseling coach, and the motivating change agent. Understanding how best to present the information to users, how to design the interface so as to entice users to interact with the program regularly, and how to motivate the user in transforming their thoughts and behaviors as a result of their use of the software is a sure path to success. For example, the best marksmen among new military recruits were those who had previously played computer games, which provided them with virtual experience in shooting down enemies that dynamically move and disappear and reappear. This sort of training can be extended to health care providers for preparation of e-emergency services or e-hazard readiness.

E-ADMINISTRATIVE AND SUPPORT SERVICES

Health care providers use ICT and e-technologies for a variety of administrative and support services:

• E-prescription
• Electronic health records
• E-supply ordering, e-claims, and remittance
• E-decision support
• E-work

E-Prescription

Prescription drug business in the United States amounts to about $100 billion per year. Attempts have been and are still being made to “e-volutionize” this industry (Menduno, 1999a). Many new companies (some of which are offshoots of more established corporations) such as Allscripts, PocketScript, ePhysician, and iScribe are entering the market of e-prescription (electronic prescribing of drugs). Most of these companies use handheld devices for order entry. Automating order entry not only improves work flow but also saves a significant amount of physicians' and pharmacists' time. Medical errors are reduced significantly, resulting in better drug use information and improved patient satisfaction (Anderson and Stenzel, 2001).

Piloting online prescription drugs, Kinetra, based in Colorado, recently launched a pilot project with network service provider ProxyMed, linking nearly one thousand physicians to Walgreen's and Eckerd pharmacies. The project also included two managed care programs that collectively manage prescriptions for more than 100 million patients. The participating physicians logged into on-line formularies and entered their patient's drug histories whenever they wrote a prescription. Benefit managers could e-mail prescription renewal requests rather than calling the physician's office. The pilot has been a great success. Lower costs and reduced medical errors provide the biggest incentives for the project (Menduno, 1999a).

Most retail pharmacies also provide the option of ordering prescription refills online. The medicine can then be picked up from the pharmacy or mailed to the patient's home. Advantages of this practice include patient convenience and probable cost-effectiveness as no waiting time is involved and human transcription errors can be drastically reduced for patients on medications for chronic conditions. Virtual pharmacies also e-mail refill reminders and medication instructions that can lead to improved patient compliance. Unfortunately, patients may attempt to misuse the system by seeking to obtain drugs without an appropriate medical prescription, including unapproved or untested drugs or herbs. The process is expected to improve as specific guidelines and regulations are enacted and enforced. The American Medical Association plans to release ethics guidelines for e-physicians who intend to authorize on-line prescriptions.

Electronic Health Records

The use of electronic health records (EHRs) has grown and improved over the last thirty years, as Chapter Four discusses at length. Electronic records provide the advantages of storing patient information in a digital format, reducing medical errors, providing feedback and reminders, and aiding in outcomes analysis. Although most current programs are based on a mainframe or a client-server architecture, the focus is rapidly shifting to a Web-based application service provider model. Web-based applications have the advantages of open architecture, standard interfaces, and data transmission standards. EHRs are being increasingly subjected to security regulations, including the Health Insurance Portability and Accountability Act privacy rules, which regulate all health care electronic data interchange.

Some of the earlier EHR programs include Medscape's Logician for ambulatory care physician practices; Epic System's EpicCare for large, multisite practices; and Cerner's Millennium products, which combine clinical and administrative tasks for large health care systems. Kaiser Permanente, the nation's largest health care group, recently partnered with Epic Systems Corporation to initiate a paperless automated medical record system for its 8.4 million members nationwide. The system will be deployed during the next few years and will provide a clinical data repository for all patient data, which is being designed to be accessible twenty-four hours a day, seven days a week, from anywhere, with the hope of improving patient care through a reduction in administrative costs. These data will also be used for outcomes analysis, cost analysis, performance assessment, and trend analysis.

Wireless and handheld devices are increasingly being used in conjunction with EHRs to facilitate order entry, to increase efficiency, and to improve work flow by providing access to patient information from anywhere (Anderson and Stenzel, 2001). Tablet personal computers (PCs) are also gaining in popularity. They are smaller and lighter than a laptop computer, but have a bigger screen and provide easier data entry than personal digital assistants (PDAs). A growing number of vendors are developing programs specifically for tablet PCs and PDAs with enhanced features such as handwriting recognition and voice recognition. The development of wireless network infrastructure and the decreasing prices of these systems are stimulating the adaptation of these devices for regular patient care.

E-Supply Ordering, E-Claims, and E-Remittance

The supply industry is estimated to about $140 billion annually. Although on-line B2B health care supply procurement is in its infancy, it has already proved that it has several benefits. Real-time inventories and competitive pricing, which is not too different from traditional advertising, enable purchasing departments to compare prices on-line and plan their purchases electronically so that inventories can be filled just as they are needed to be filled (just-in-time inventory management). Orders can also be tracked digitally in order to support timely delivery. On-line ordering is a win-win situation for both purchasers and vendors; e-manufacturers can interact directly with e-purchasers, eliminating intermediaries. This direct interaction can ultimately reduce prices for the purchaser and increase profit margins for the manufacturer as the manufacturer will not over-manufacture certain parts and purchaser reduces holding costs in unwanted inventories.

Among other tangible benefits, a data warehouse can be used to track purchased items, and data mining can be applied to unravel usage patterns. Electronic auctions can be used for on-line trading of health care supplies and goods, as in supply chain management of any other business. Requests for proposals can be sent electronically, thereby saving time. Because hospitals often stock 100,000 units of popular items, e-procurement will work only if the searching for a match between supplier and purchaser is automated, which currently is not often the case (Arbietman, Lirov, Lirov, and Lirov, 2001; DeJesus, 1999; Menduno, 1999b).

The Alamo City Medical Group in San Antonio, Texas, comprises sixteen family physicians in eight different locations. According to their director of nursing, ordering supplies used to take about a day every month, filling out purchase orders for multiple vendors. The nurses at practice sites used to go through their supply closets to see what they needed. Since the group has switched to e-supply ordering, the process usually takes less than two hours every month. The on-line purchasing vendor has customized order forms for each practice site that are based on established ordering patterns. The nurses check off these forms, indicating what they need, and the order is entered via the vendor's Web site. Confirmation is instantaneous, and the order arrives within two days. The group reports a savings of about $8,000 every month due to savings in holding costs for inventories (35 to 40 percent of the medical supply budget) (Terry, 2002).

Increasing costs put pressure on health care providers and payers to improve decision-making processes and control expenses. The number of hospitals that submit their claims electronically has been rising over time generating an immediate effect on return on investment (ROI). According to John Glaser, vice president and chief information officer of Partners Health System, Boston, “The manual process of determining eligibility doesn't work well. We have a claim denial rate of 11 percent. Our goal is to reduce that to 5 percent. In large part that comes from online technologies for eligibility verification, pre-certificate referral authorization. The ROI is spectacular” (Solovy, 2000; Riley and Korpman, 2001).

E-Decision Support

E-decision support systems are data analysis and modeling tools that automatically track patterns and trends in a data repository or data warehouse (Tan with Sheps, 1998; Tan, 2001). The resulting analysis is then used to guide decision making. In essence, it is the process of converting raw data into useful information and then into rich and valuable knowledge. The primary types of e-decision support system (e-DSS) in health care include marketing, cost management, forecasting, and case-mix systems. Executive information systems are e-decision support systems that allow user-defined views of data. On-line analytical processing tools are becoming increasingly popular as a form of decision support. These provide the ability to slice and dice the data into various views and levels. The information obtained from these systems can be used to track outcomes, to develop clinical practice guidelines, or to develop e-disease management programs for target populations (Forgionne, Gangopadhyay, Klein, and Eckhardt, 1999).

Most health maintenance organizations structure their health plans by using an e-DSS to design benefits based on member characteristics, claims, and revenue information. Data patterns can also be used to detect possible fraud and system abuse (Callan, 2000). Clinical decision support systems have yet to gain much popularity. An example of such a system is Quick Medical Reference, which helps make clinical diagnoses based on signs and symptoms that have been entered into the system. Chapter Ten describes the application of an e-DSS to aid clinical diagnosis and management of lower back pain, while Chapter Eleven discusses the use of data mining and clustering methodology to detect hidden trends and data patterns.

E-Work

Now we will take a closer look at e-work in general, which has evolved from the use of information and communication technology and e-decision support systems for general e-health and other e-administrative and support applications. The users of these various e-technologies may be individuals, groups, organizations, or communities at large.

According to recent statistics, in 2000, nearly 80 percent of the world's largest companies used the Internet for recruiting, up from 60 percent in 1999 and 29 percent in 1998. On-line recruitment can translate into huge cost savings for an organization. According to a study by Creative Good, an e-commerce consulting firm in New York City, a facility can save up to $8,000 per person hired ($2,000 in advertising costs and $6,000 in time spent on interviewing on site because sending recruiters to various conferences and placement sites is costly) (Goldsborough, 2000). The health care industry has followed the general trend in this regard. Some popular recruiting sites include emedjobs.com, healthcareersonline.com, hospitalhub.com, medhunters.com, and nurserecruiter.com.

Advances in technology have removed the physical and geographic constraints that required workers to be at their workplace in order to accomplish productive work. E-work, or telework, is gaining popularity in administrative, research, and other support components of health care that do not require direct patient interaction. According to the International Telework Association and Council, on average, telecommuting increases productivity by 22 percent while decreasing employee turnover and absenteeism by 20 percent and 60 percent, respectively.

E-work or telecommuting options include working from home, working from a satellite office (a remote office location usually placed within an area of concentration of employee residences), a neighborhood work center that provides work space for employees of different companies in close proximity to the employees' residences, and a virtual mobile office that enable an e-worker to work from a car, an airport, a hotel, or any other location, as long as connectivity can be achieved. Employees may “e-work” part-time or full-time. E-work, however, entails specific challenges that need to be overcome, including management control issues, culture change for the organization, start-up costs, security issues, distractions, and lack of support services at home or in other locations where the e-work is to be performed (Dougherty and Scichilone, 2002). Examples of e-work include having online medical transcriptions performed and/or call centers manned by e-workers located in India and China.

TeleRehab™ at INTEGRIS Jim Thorpe Rehabilitation Center

Few e-medicine programs consist of only one application or discipline. Rather, most of them are a combination of the electronic clinical or administrative categories that we have just discussed. INTEGRIS Rural Health received a rural e-medicine grant (1997–2000 and 2000–2003) from the Health Resources and Services Administration in the Office of Advancement of Telehealth, a US government agency, to improve access to health care for rural individuals across the life span, to reduce isolation of rural medical practitioners, and to collect and disseminate resulting data. Under this grant, INTEGRIS Jim Thorpe Rehabilitation Center (IJTRC) provided e-rehabilitation services for physical therapy, occupational therapy, speech therapy, rehabilitation psychology, and vocational rehabilitation. Occasionally, other specialties such as psychiatry and pharmacology were included. E-health techniques were also used for administration, education, transfer of knowledge, and peer support services associated with the program.

IJTRC provides team-based, individualized restorative treatment for patients at all stages on the rehabilitation continuum of care. The IJTRC team has effectively used telerehabilitation to help individuals with disabilities reintegrate into their community in a variety of settings, including home, work, and school (Clark and Scheideman-Miller, 1999; Clark, Dawson, Scheideman-Miller, and Post, 2002; Dawson, Clark, and Scheideman-Miller, 1999). As is evidenced by the wide range of disciplines mentioned, e-rehabilitation lends itself to a multidisciplinary approach, probably more than traditional medical specialties limited to physical sites would allow. Table 7.1 depicts the range and scope of e-rehabilitation services offered at IJTRC.

E-rehabilitation sessions have been conducted using T-1 (high-speed leased network connection line) and the integrated services digital network (ISDN), as well as the “plain old telephone system” (POTS). T-1 and ISDN are used primarily to connect with rural school districts or hospitals because they provide better resolution and fewer transmission delays than low-technology systems. The POTS is the primary telecommunication technology used for therapy services to home-based patients.

Rehabilitation, much of which is usually conducted through touch, is often difficult to envision being delivered remotely. One of the reasons for the success of the IJTRC program was a core group of clinicians and therapists who were able to focus on patient needs, putting aside uncertainties and barriers in order to address a growing underserved population. This driving purpose led them to devise safe and effective alternatives to traditional modes of delivery. A physical therapist, for example, might use a caregiver in a home situation as an assistant to lower the probability of patient falls, provide patient props, reinforce therapist instruction through cueing, and promote compliance with an in-home exercise regimen. A speech language pathologist might use toys such as an automated reader for joint play with the client in order to sequence language exercises to assist with reading skills. A psychotherapist could address adjustment to disability for the caregiver as well as the patient in the safety and anonymity of their home setting. This program has been developed over a period of three years. To date, a total of 3,711 consults have been provided through the use of e-rehabilitation technology, including 82 audio or verbal therapy consults, 39 occupational therapy consults, 126 physiatry consults, 539 physical therapy consults, 2,837 speech therapy consults, and three vocational rehab consults, in addition to other services (for example, adult mental health consults). Together, these sessions add up to 139,394 minutes of therapy as shown in Table 7.2.

TABLE 7.1. E-REHABILITATION APPLICATIONS AT INTEGRIS JIM THORPE REHABILITATION CENTER

Type of Intervention	Purpose
Telementoring	Provision of training or expertise to distant or rural clinicians
Telemonitoring	Ongoing assessment of specified condition or situation
Teleconsultation	Provision of professional impressions or direction in regard to course of action or treatment planning
Tele-education	Continuing education, to develop content expertise
Telesupervision	Review of patient status or progress to satisfy regulation requirements
Teletherapy With physical intervention Without physical intervention	Facilitation of patient's functional recovery through physical instruction Facilitation of patient's functional recovery and improvement through suggestions

The acceptance of e-rehabilitation is evidenced by improved outcomes such as better cognition, hearing and language skills. Over 67 percent of home care patients cite high satisfaction and say that they would use e-rehabilitation again.

TABLE 7.2. CLINICAL E-REHABILITATION ENCOUNTERS AT INTEGRIS JIM THORPE REHABILITATION CENTER (April 1999–August 2003)

Note: Clients were located in schools, hospitals, and residences during the encounters.

Conclusion

The health care marketplace is expanding and evolving at a rapid rate, and the focus is on automation, paperless offices, and increased efficiency and effectiveness of decision-making capabilities through the increasing use of information technology and e-technologies. According to Forrester Research, the health care purchasing market will reach $370 billion by the year 2004, and 35 percent of e-supply hospital procurement could be through the Web. Needs forecasting could be achieved by integrating e-supply acquisition and on-line inventory management with direct e-care (DeJesus, 2000). Combining the capabilities of the Internet with other interactive e-technologies such as voice recognition systems and telephone-based triage lines will continue to evolve and will greatly reduce unnecessary medical services and costs. E-medicine, e-commerce, e-clinical care, e-home care, e-learning, e-prescription, e-supply chain management, e-decision support, and e-work are all part of the larger e-health applications that can change the way health care products and services are to be delivered to e-consumers, the underserved, and the homebound.

The e-speech therapy case study at the end of this chapter supports the concept that telecommunications can be used to effectively deliver both articulation and language interventions to students in rural schools. The use of e-technology has resulted in the delivery of cost-effective, specialized health care to rural communities and is helping to bring rural schools into the new millennium on the cutting edge of specialized e-rehabilitation service delivery.

New technological standards such as XML are further simplifying e-health by permitting communications between and among parties independent of hardware platforms, operating systems, business applications, or database management systems. Instead, these standards use the local data definitions of the end user (Aggarwal and Travers, 2001). For patients, this will eventually translate into e-messages that will be used in medical triage, e-management of appointments and schedules, e-prescription refills, e-previsit preparation, and e-postvisit follow-up. The payoffs are in the form of more efficient use of time, documentation of all communications, fewer physical office visits, and improved visit quality (Joslyn, 2001). E-health is not the future but the present, and it will complement and not replace traditional health care services.

Chapter Questions

1. What general medical services lend themselves to electronic transmission of information?
2. What rehabilitation or ancillary services might be incorporated in e-medicine?
3. What adaptations could facilitate clinical and administrative acceptance of e-rehabilitation?
4. What are the external driving forces in your organization or community (for example, legislation, licensure, reimbursement, confidentiality) that contribute to either the potential success of or the existing barriers to the implementation of an e-health program?
5. What existing human resource capital could contribute to the operational implementation of an e-rehabilitation program in a health facility that you may have personally visited?

References

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E-Speech Therapy for Children in a Rural Oklahoma School Case

Cynthia Scheideman-Miller, Pam Forducey, Sharon S. Smeltzer, Avery Clouds, Bob Hodge, David Prouty

Since the Individuals with Disabilities Education Act (IDEA) was implemented in 1990, schools have been required to supply specific specialty services such as speech therapy, occupational therapy, and physical therapy. Because of their geographic locations and sparse populations, many rural communities do not have the resources to provide these services to their students. Traveling to metropolitan areas where these services are more readily available is hard on the children and their families.

INTEGRIS Rural Telemedicine, INTEGRIS Jim Thorpe Rehabilitation Network, Choctaw Memorial Hospital, and the Hugo Public Schools collaborated on an initial e-speech therapy program in the spring of 1999 to see whether federally mandated speech therapy services could be delivered with two-way, interactive videoconferencing. This five-week pre-pilot program was conducted between the metropolitan and rural hospitals over a dedicated T-1 line. The effectiveness of this mode of delivery, including the success of the speech therapy and the satisfaction of the therapists, teachers, students, and parents, was measured.

Favorable results from the pre-pilot program led to an expanded program in which the services were delivered directly to the rural public school from the metropolitan hospital, using H323 and H320 videoconferencing equipment via OneNet, Oklahoma's telecommunications backbone.

Background

More than 51 million Americans live in areas classified by the U.S. Office of Management and Budget as nonmetropolitan. Rural populations, which constitute one-fifth of the U.S. population, frequently have difficulty in accessing adequate health care. Less than 11 percent of the nation's physicians are practicing in nonmetropolitan areas (Office of Rural Health Policy, 1997). Specialty services are even more limited than primary care and may be completely unavailable. Although the need for specialty services is high in rural areas, rural residents often go without these services. Geographic and financial barriers pose a threat to the provision of specialty care services for the rural population.

Populations in some rural communities fluctuate dramatically, contingent on recreational seasons and agriculture. When populations expand, demands for services, including special services for individuals with disabilities, also increase. At other times, a single individual may be the only one in the entire county with a specific medical condition and resultant physical or cognitive impairment.

IDEA guarantees all children with disabilities a free, appropriate public education, emphasizing special education and related services designed to meet their unique needs. All states are required to abide by this law; the states receive federal funding for special education, while the local education agency or school system is responsible for identifying, locating, and evaluating all children who require special education services. Under IDEA, schools must supply specific services such as speech therapy, occupational therapy, and physical therapy. It is often a struggle for school administrators to secure these services, and some rural schools may go for years without a speech language pathologist (SLP). Even when an SLP is hired, the newly hired professional often leaves for a metropolitan area where the caseload is lighter, pay is better, and peer support is available. One rural community offered wages that were 43 percent higher than the state average and still had difficulty obtaining a speech pathologist. Rural SLPs report many challenges: one SLP has to travel half of the day in order to work with children at geographically distant sites; another has trouble getting state universities to return calls or answer questions regarding students with complex medical conditions.

One alternative is for students to travel to a metropolitan area where these specialty services are more readily available. This incurs additional costs, since the schools have to pay for the trips. It also entails physical and financial stress on the children and their families, including lost work time and additional travel expenses. Children traveling such distances are more fatigued and less attentive to therapy, which lessens the sessions' effectiveness. Moving to a metro area where services are more readily available is a theoretical option, but most of the families make a living in agriculture-related fields. In addition, the family ties and social support of a rural area are usually strong, so that even if a family can move, the different culture of a metropolitan area and lack of family and community support create additional burdens. Financially viable alternatives that produce positive outcomes are clearly needed.

E-Speech Therapy Program Development for a Choctaw County School

Speech therapy primarily involves sessions of interactive speaking and visual cues in which a therapist assesses and guides a student. Two-way interactive videoconferencing has been used in Nebraska to deliver e-speech therapy to patients who had difficulty speaking subsequent to a stroke. This experiment brought specialty consultation and treatment to stroke patients who otherwise would not have had access to such care. Expanding on this idea, an e-speech therapy intervention for students in a rural Oklahoma school was developed and evaluated.

The first step was to determine whether e-speech therapy could be delivered in a cost-efficient and timely manner. It was also important that all the major stakeholders, including the therapists, administrators, parents, and students, be comfortable and supportive of the intervention. A pre-pilot program was planned to minimize technological and logistical problems. In order to eliminate as many extraneous variables as possible, the rural school needed an established relationship with the metropolitan hospital whose infrastructure would support the e-therapy sessions and carry the project to the next stage.

The selected site for the pre-pilot project was the town of Hugo, located in Choctaw County, Oklahoma. Choctaw County is located in the far southeast corner of Oklahoma, on the Texas border and near the Arkansas border. The population of Choctaw County is 15,302. The largest town, Hugo, has 5,978 residents. In Choctaw county, the poverty level is 49.3 percent; the child poverty level is 44.2 percent; and 80 percent of the children are on the school lunch program. Under federal guidelines, Choctaw County is both a medically underserved area (MUA) and a health professional shortage area (HPSA).

The Hugo Public School System has a school SLP, but at the time of the pre-pilot project, the number of students who needed speech therapy services was greater than the caseload allowed by the state. Supplemental services were required to meet federal mandates, but these services were difficult and expensive to secure. Choctaw Memorial Hospital in Hugo was part of the INTEGRIS Health System, a not-for-profit health care system based in Oklahoma. INTEGRIS Rural Telemedicine, INTEGRIS Jim Thorpe Rehabilitation Center (IJTRC), and Choctaw Memorial Hospital had a longstanding affiliation. Likewise, Choctaw Memorial Hospital and the Hugo Public Schools served the same community and had a strong alliance. The need for services, the availability of a rural SLP to help with monitoring, plus existing affiliations between facilities made Hugo an ideal site for the study. All four entities collaborated in the e-speech therapy study for four weeks in the spring of 1999.

E-Technology for an E-Speech Therapy Program

The initial program was conducted at the Choctaw Memorial Hospital. Southwest Medical Center, of which IJTRC is part, also participated via video bridge. The connection was bridged through INTEGRIS Baptist Medical Center (IBMC), which is the core of the INTEGRIS Health System. Choctaw Memorial Hospital used an H320 videoconference unit connected via a dedicated T-1 line to the video bridge at IBMC.

Data and video services are distributed across the INTEGRIS Wide Area Network (WAN), which provides connections to over sixty locations throughout the state and access to specific extranets throughout the nation. The INTEGRIS WAN core is a Newbridge 3645 carrier-grade switch. This hardware allows INTEGRIS to port voice, video, and data over various bandwidths to remote locations. This site also houses a VTEL/EZENIA 320 standards-based video bridge capable of direct video connections to INTEGRIS facilities, as well as an EZENIA 320/323 gateway/gatekeeper. The gateway enables H320 or H323 connectivity throughout the network and beyond. An Ascend inverse multiplexer connected to an integrated services digital network (ISDN) primary rate interface gives the system the ability to connect both nationally and internationally.

Evaluation of E-Speech Therapy Sessions

INTEGRIS Rural Facilities was awarded a federal Rural Telemedicine grant from the Office for the Advancement of Telemedicine under the Human Resource and Services Administration. This grant supplied seed money and project oversight to help develop, oversee, and evaluate the pre-pilot e-speech therapy program. IJTRC, also part of the INTEGRIS System, employed board-certified SLPs to supply the needed services.

Education prior to each stage of program development was essential to ensure buy-in from key stakeholders and commitments from all partners. The Hugo Public School System was familiar with interactive technology, having used classroom video technology to share a language teacher for several years. This familiarity facilitated the implementation of the pre-pilot program. School administrators were brought in from the beginning and played an instrumental role in educating the school board and community members about the potential of this application. Presentations were made to the school board and to the Oklahoma Healthcare Authority (the state Medicaid agency that reimburses the schools for part of the services) prior to launching the project. An open house and technology demonstration was organized for potential participants in the program, their parents, teachers, school administrators, and hospital and school board members.

Once community orientation and informed consent procedures were completed, the five-week program commenced, using an intervention group of six students and a control group of three students. The intervention group consisted of three boys and three girls ranging in ages from three to nine. The control group consisted of one boy and two girls ranging in age from four to ten. The elementary-aged students' diagnoses ranged from mild to moderate articulation deficits. The prekindergarten group's diagnoses included cerebral palsy and cleft palate in addition to articulation disorders.

A hospital-based metro SLP from IJTRC conducted the interventions with the students. The students were transported to Choctaw Memorial Hospital in Hugo to use the videoconferencing equipment (VTEL FRED H320 unit) that was already in place. The metro SLP planned the sessions and conducted them over the INTEGRIS video network, using 384 kilobytes per second on a dedicated T-1 line from Oklahoma City. Hugo is approximately 178 miles, or a four-hour drive, from Oklahoma City. The Hugo school SLP was present in the Hugo conference room for all of the e-therapy sessions. This ensured that the student was receiving appropriate intervention, could understand what the metro SLP expected of them, and could respond appropriately. In addition, the metro SLP provided consultation services to the SLP in Hugo before and throughout the project. This added to the value of the relationship between a metro site and a rural site.

The therapy sessions were conducted in an area adjoining the cafeteria with an accordion room divider, which decreased visual but not auditory distractions. These distractions lessened the effectiveness of the therapy and raised the issue of confidentiality problems. This problematic setup would need to be improved for future implementations. Sessions must be held in a private area without extraneous disruptions.

Evaluation Outcomes

Due to the limited time frame and small number of students evaluated in the pre-pilot program, no major change in satisfaction levels was anticipated. Thus, organizers were pleasantly surprised to find that therapists and teachers saw significant improvement in the students' scores on a standardized pediatric rehabilitation assessment tool (WeeFIM) in the cognitive domains of social interaction, problem solving, and memory after they had participated in the e-speech therapy for only five weeks. Students less than seven years of age were found to be less attentive to the speech therapy sessions; as a result, it was decided to include only students seven years of age or older in the pilot study.

A nonstandardized customer survey tool was given to measure satisfaction. Satisfaction was high for all parties in regard to both the use of the technology and functional outcome measures, and it was highest for parents and students. Teachers found that e-therapy was beneficial because there were many observers, not just one therapist. Through the use of interactive video, multiple perspectives on the problems and treatment of each student emerged. The older children (second grade and above) responded better to the video interaction. One older child in particular thought that he was on a television program and made tremendous improvement, because he was doing his best while receiving individual care.

Feedback on the project from parents, students, therapists, and school administrators was favorable. The school board president informed his board that he was impressed when he saw an e-speech therapy session. He stated, “Through telemedicine, we are able to tap into the best of the best.” Discussions were conducted among the stakeholders from both the rural and metropolitan areas. Meetings were held between the metro and rural SLPs on how to conduct sessions; strategies for incorporating a teacher's aide; the individual education plan (IEP) process; and selection of student candidates for the program. The school principal worked with the Rural Telemedicine Project and clinical directors on reimbursement, coding of medical data, and logistics. The project's technical director worked with the communications coordinator for the school's on-line hardware and software implementation and technology selection.

Expanded E-Speech Therapy Program

Favorable results from the pre-pilot program led to an expanded program, a collaboration between INTEGRIS Rural Telemedicine, IJTRC, and the Hugo Public School System, in the fall of 1999. Based on their IEP, eleven students were selected to participate in the expanded program. The project was initially approved for a duration of one school year (thirty weeks), but its success led to the approval of a second school year. The eleven students were in second grade or older, with either language or articulation deficits. During the two years of the pilot study, the students received individual one-hour speech therapy interventions as scheduled, resulting in almost a thousand virtual visits. Clinical outcomes, cost-effectiveness, and satisfaction of therapists and students with the telemedicine sessions were measured and reported elsewhere (Clark and Scheideman-Miller, 1999).

Implications for the Future

The e-speech therapy pilot project proved that telecommunications can be used to effectively deliver both articulation and language interventions to students in rural schools. This result was chronicled in a report to the American Speech-Language-Hearing Association's executive board. The Issues in Credentialing Team (1998) for that organization stated that it believed “that the remote delivery of audiology and speech-language pathology services through technology (telehealth) has the potential to become a more widely used mode of clinical service delivery and a rapidly expanding marketplace niche for our professions.”

Future project directions include offering e-speech pathology services to additional schools—initially rural ones, then possibly metropolitan ones. Additional services—such as e-physical therapy, e-occupational therapy, and e-behavior modification therapy—are being explored. The use of e-technology has resulted in the delivery of cost-effective, specialized health care to rural communities in Oklahoma and is helping to bring Oklahoma into the new millennium on the cutting edge of specialized e-rehabilitation service delivery.

Case Questions

1. Why do you think students older than seven years of age in rural communities are more responsive than younger students to the e-speech therapy sessions?
2. Can you think of any way to improve this program so that it can provide other forms of therapies that rural children may also need in an e-health context?
3. What are some measurable clinical outcomes of e-speech therapy? How would you measure these outcomes?
4. If you were asked to evaluate an e-speech therapy program for an underserved population such as the one discussed here, how would you go about doing so? What criteria would you use? What do you think would be the impacts of your evaluation results?

References

Clark, P., & Scheideman-Miller, C. (1999). Telehealth “pre-pilot” successful in Oklahoma. Advance for Speech-Language Pathologists and Audiologists, 9, 18–19.

Issues in Credentialing Team, American Speech-Language-Hearing Association. (1998, August). Telehealth issues brief: A report to the ASHA executive board from the Issues in Credentialing Team.: American Speech-Language-Hearing Association.

Office of Rural Health Policy, Health Resources and Services Administration, U.S. Department of Health and Human Services. (1997, September). Fact sheet—rural physician; facts about rural physicians. Source 1. Rockville, MD: Author.

This chapter was made possible by grant number 5H2ATM00245–06 from the Advancement of Tele-health, Health Resources and Service Administration, U.S. Department of Health and Human Services.