Health-Care On-Ramps A Road Map to Western States' Information Highways April 1998

PREFACE AND ACKNOWLEDGMENTS

The report is based upon an 18-state survey conducted by the Western Governors' Association (WGA) and the National Association of State Telecommunications Directors (NASTD) between April and September of 1997. Surveys were sent to both telecommunications directors and rural health/telemedicine experts in each state and they were asked to collaborate on a response. The completed questionnaires were compiled into a draft report which was then circulated to each state to confirm the information. The final version is before you.

Two notes on the information presented herein. First, we regret that no information was submitted by the State of Kansas. Second, changes are occurring rapidly in the field of telecommunications and telemedicine. As a result, the reader should be aware that the information contained in this report may quickly become dated in some cases. A list of survey respondents and other contacts appears in Appendix Three to enable the reader to confirm the most current information.

WGA received funding for the development and production of this report from the National Library of Medicine (NLM). It was a pleasure to work with NLM and in particular Dr. Elliot Siegel, Associate Director for Health Information Programs Development. Their insights and advice during the project were extremely valuable and much appreciated. WGA was capably assisted in this effort by Jack Gallt, Staff Director of NASTD who in turn was assisted by Jennifer Mabry. NASTD had the difficult tasks of convincing its Western members to respond to the lengthy survey and then to compile that information into a form intelligible to laymen. WGA extends its special thanks to Jack and NASTD for their professional efforts. Jack and NASTD may be reached at 606-244-8178 or by e-mail at jgallt@csgcomm.csg.org.

WGA also wishes to thank each of the state individuals that responded to the survey. We hope that you agree with us that the time you invested resulted in a valuable final product. Other individuals and organizations not listed in the appendix that assisted WGA in this effort include: Vera Kloepfer, Colorado Telehelath Network; Jerry McCarthy, Colorado Rural Health Telecommunications Coalition; Dr. Doug Perednia, Association of Telemedicine Service Providers; Dr. Bob Flaherty, Montana Area Health Education Center; Neal Neuberger and John Scott, Center for Public Service Communications; David Albert, Washington State Board of Health; Frederick Pearce, The Alaska Telemedicine Project; Mike Kahoe, California Governor's Office; Steve Marks, Oregon Governor's Office; Jimmy Glotfelty, Texas Governor's Office; and Andy Klein, Alaska Lt. Governor's Office.

This report was prepared by Christopher McKinnon and Paul Orbuch of the WGA. We received professional assistance from other WGA staff including Karen Deike, Toni McCammon, Debbie Kinsley, and Sharon Dawn. Additional copies of the report and more information on the WGA and its telemedicine work can be obtained on the WGA website at www.westgov.org. You may contact us at Western Governors' Association, 600 17th Street, Suite 1705 South Tower, Denver, CO, 80202. Phone: (303) 623-9378; Fax: (303) 534-7309.

TABLE OF CONTENTS

I. EXECUTIVE SUMMARY, FINDINGS & CONCLUSIONS

II. INTRODUCTION

III. TELEMEDICINE POLICY AND MANAGEMENT ISSUES

A. Development and Management of State Telemedicine Initiatives

B. Recommended Roles for Key Players in the Development and

Implementation of a Statewide Telemedicine Vision

C. Organizing Frameworks

D. Integration of Telemedicine and Statewide Telecommunications Systems

E. Funding for Telemedicine

IV. SNAPSHOT OF WESTERN STATE TELEMEDICINE ACTIVITIES/SERVICES

V. STATE TELECOMMUNICATIONS NETWORKS AND INFRASTRUCTURE

A. Introduction

B. Western State Telecommunications Activities

C. Key Findings & Conclusions

D. Strategic/Planned Telecommunications Activities

VI. SNAPSHOT OF WESTERN STATE TELECOMMUNICATIONS NETWORKS -- [not included in web version]

VII. APPENDICES

1) Glossary of Telecommunications Technology Acronyms

2) State-by-State Data on Current and Planned Telecommunications Infrastructure And Services (Tables) -- [not included in web version]

3) Western State Telemedicine and Telecommunications Contacts

I. EXECUTIVE SUMMARY, FINDINGS & CONCLUSIONS

Through the use of telecommunications technology, there is the potential to lessen the rural health-care resource shortage while widening the scope of health resources available in urban areas. The Western Governors' Association (WGA) recognized the future value of telemedicine in 1995 while at the same time identifying policy and legal barriers to its widespread use. One of these barriers was that of states' telecommunications infrastructure and the need for states to incorporate health-care applications into telecommunications planning, while also working to develop interconnection capabilities with neighboring states. This report was undertaken to develop the background information necessary to bridge the telecommunications infrastructure barrier to telemedicine. To accomplish this, telecommunications and rural health leadership in WGA states were surveyed and the information compiled.

First, we explore the development of telemedicine policy in the Western states. The role and interest of governors, legislatures, higher education, telecommunications providers, and health-care providers is examined, and recommendations are made as to an appropriate role for each of these stakeholders. We also detail the methods used to develop state policy in this area, be they governors' task forces, consortia, or no methodology at all. The extent to which a few states have attempted to integrate telemedicine with information technology planning is illustrated, as are the funding resources for state telemedicine efforts. A state-by-state snapshot of significant telemedicine activities and services is also provided.

In Section V, the development and growth of Western state telecommunication networks is profiled. Many states have undertaken long-range strategic planning regarding their telecommunications infrastructure given the importance of the networks to the state and the rapid pace of technological changes in the field. A state-by-state profile is provided that illustrates each state's video, data, and voice services infrastructure and the corresponding services that are offered.

The telemedicine and telecommunications research developed regarding the Western states gives rise to the following findings:

* Initially, most telemedicine networks developed independently on a small scale and were relatively isolated from other telemedicine networks.

* Western state and private telecommunications networks and services are evolving rapidly. This evolution, combined with advances in information technologies, is making telemedicine more efficient, effective, and affordable.

* Recent changes in federal law and regulation have also made providing medical services and education via telecommunications more affordable by allowing physicians to be reimbursed for services and by creating a universal service fund that can offset higher telecommunications rates in rural areas.

* States are employing various strategies to coordinate and implement telemedicine activities, including public/private consortia, task forces, telemedicine conferences, strategic plans, and network improvement.

* Few states have integrated telecommunications and telemedicine strategic planning activities despite the fact that each influences the other dramatically.

* There is a small but growing number of examples of state telecommunications networks connecting to other states' networks to provide medical education. However, certain legal and policy barriers limit the ability to provide medical services via telemedicine over these interstate connections.

* All states surveyed indicated an interest in interconnecting their telecommunications networks with other states' networks.

* States are continuing to develop integrated statewide networks to provide voice, data, and video communications services to multiple end users including state agencies, local governments, and public health-care facilities among others.

In light of the above findings, the following conclusions emerge:

1) The costs and benefits of providing medical services and education via telemedicine are still being evaluated. States should share the results of these evaluations with one another to ensure that states invest tax dollars in telemedicine activities that provide the biggest bang for the buck.

2) Governors and state legislators should insist on a tighter integration of strategic planning efforts for telemedicine and telecommunications. This should be done on a statewide basis (health agencies, educational institutions, general services agencies, etc.) given the substantial investments states have and will make in equipment. Private sector telecommunications companies, telemedicine equipment manufacturers, and private medical services providers should be at the table as well.

3) For telemedicine to reach its full potential, governors and legislators should resolve both interstate and intrastate legal and policy barriers.

II. INTRODUCTION

Providing a sufficient level of health-care resources to residents of the rural West of the United States has long been a challenge for state governments. Despite greater health-care needs in rural areas, urban states have nearly 42 percent more physicians relative to population than rural states. Rural residents are also more than twice as likely to face a shortage of primary care physicians than the nation as a whole. This disparity has increased in the last decade. For example, from 1988 to 1992, the number of rural citizens living in primary-care shortage areas rose by twenty-five percent, to a total of four million individuals. In the West, rural populations range from California's at just over three percent and a population per square mile of 198 persons to Wyoming's at 70 percent with five persons per square mile. The resource shortage in rural America is in part caused and compounded by the difficulty these areas have in recruiting and retaining qualified physicians.

The dramatic national changes occurring in the health-care system of the United States also present a challenge to states. Supporting primary care clinicians for their needy rural or urban residents is a critical concern for every governor. At the same time, costs for specialized health care can be prohibitive for state residents regardless of location. State medical centers facing exclusion from local managed care networks and reduced revenues and public support are looking to expand markets for their services regionally, nationally, and internationally.

The good news is that the use of telemedicine and the development of telemedicine networks is growing. Telemedicine is the provision of health-care services using interactive telecommunications technology. Although much of that growth has been initiated by individual telemedicine networks instead of as part of an overall statewide vision and strategy, that situation appears to be changing. Western governors have taken a leadership role, both individually and collectively, to ensure that telemedicine continues to expand its reach. In 1995 the governors directed the Western Governors' Association (WGA) to develop an action plan that would provide them with guidance to support the development of telemedicine. The WGA's Telemedicine Action Report does just that. It identifies six legal and policy barriers to the expansion of telemedicine and provides recommendations on how to overcome them. In June, 1995, the governors endorsed these recommendations and established regional policy on telemedicine by adopting a WGA resolution entitled, "Telemedicine in the West."

One of the barriers identified in the Action Report is that of telecommunications infrastructure. It was recommended that states factor emerging health-care applications such as telemedicine into state telecommunications and information technology planning and procurement. Western states have increased the integration of health-care needs with information technology planning since 1995. In order to further this objective, this report examines state strategies for implementing telemedicine applications and details the evolution toward the integration of state telecommunications networks and telemedicine applications. We also provide basic telecommunications network information for each of the Western states that will enable other states to learn about their neighbors and consider opportunities for regional interconnection.

III. TELEMEDICINE POLICY AND MANAGEMENT ISSUES

There is great potential for telemedicine to lessen the rural health-care resource shortage by bringing physicians and specialists to a significant number of citizens. Urban residents are also beginning to learn the value of telemedicine. Telemedicine, broadly defined, and as defined for purposes of WGA's survey of the states, is the provision of health-care services using interactive telecommunications technology. It includes all forms of health-care delivery including diagnosis, consultation, treatment, transfer of medical and other health-related data, education and population-based health promotion.

Several recent developments at the national level are shaping the future of telemedicine. The Balanced Budget Act of 1997 directed the Health Care Financing Administration to allow physicians to be reimbursed through Medicare for services provided to residents of certain rural counties via telemedicine. A lack of reimbursement for telemedicine services has long been one of the biggest barriers to the practice, and the new Medicare policy is a major breakthrough likely to lead to increases in both public and private use of telemedicine.

In addition, in February 1996, the President signed into law the Telecommunications Act of 1996, the first revision of U.S. telecommunications law since 1934. The Act's provisions on universal service are particularly relevant to rural telemedicine providers. The extremely high cost of rural telecommunications rates have inhibited rural telemedicine projects for some time. The Federal Communications Commission continues to implement the provisions on universal service but it has preliminarily decided to provide up to $400 million in funding to decrease telecommunications rates for rural health-care providers. It remains to be seen, however, the extent to which rural telemedicine providers will access this funding. Finally, and importantly, the technologies used in telemedicine applications are becoming cheaper and therefore more ubiquitous. For example, in the past eight years, the cost of a typical telemedicine system at a rural clinic has declined from $300,000 to about $22,000 today.

The challenge for states in taking advantage of these national level changes as well as the information technology evolution taking place within the states is to bring the right players together, create a statewide telemedicine vision, and integrate that vision into the broader state telecommunications planning process. Funding issues must also be considered during each of these phases. This report provides states with lessons from their neighbors in this regard while also illustrating the present extent of each state's telemedicine activities and capabilities.

To assess the policy and management issues impacting telemedicine, survey respondents were asked to give their subjective views on a number of questions. Those questions included their views on the current level of interest of key players in the state in telemedicine and the role these players are and should be playing. In addition, respondents were asked what steps the state had taken to evaluate or promote the use of telemedicine and to what extent the state had tried to integrate telemedicine into statewide telecommunications planning, private networks, or with other states' networks.

Development and Management of State Telemedicine Initiatives

Interest of Key State Players

The states that have the most well developed telemedicine systems and policies are, not surprisingly, the more rural states and states where governors have taken an active leadership role. In these states, survey respondents generally rate governors' interest in telemedicine as very high.

For governors, the interest in telemedicine is seen as coming from a desire to better utilize the existing infrastructure, an interest in telemedicine as a part of the broader telecommunications deregulation debate, or as part of state's economic development strategy. In addition, some governors' interest is perceived to stem from concerns about providing equitable access to health care and extending cost effective health-care services to rural areas. The only negative influence on gubernatorial interest was a perceived lack of demand for telemedicine services and the potential cost of the equipment and services.

State legislators on the other hand are perceived as only "somewhat interested" in telemedicine applications in their state. Exceptions to this generalization are Texas, New Mexico and Nebraska legislatures which are rated as "very interested." Legislators' perceived lack of interest in telemedicine is attributed to their fiscally conservative nature, their sense of a lack of demand for telemedicine, the investment cost to make telemedicine operational, or because there is no interest from constituents. The perceived positive influences on legislators were telemedicine's ability to address chronic shortages of basic health care, federal attention and interest in promoting telemedicine, and the possibility of telemedicine lowering health-care costs.

As expected, higher education and private telecommunication's providers are rated as "very interested" in telemedicine applications broadly defined. The telecommunication companies see a revenue potential from expanded use of telemedicine. Telecommunications companies are also seen as being influenced by demands for upgraded service and a desire to create a market to support additional investment in system. Higher education's interest is seen as a desire to help advance infrastructure needed for distance learning, to expand the applicability of existing infrastructure, and to provide educational and clinical links for students and medical residents.

A surprising result was the merely "somewhat interested" rating respondents give to both public and private health-care providers' interest in telemedicine. Private health-care providers were perceived as slightly more interested than public health-care providers, but both rated below governors and higher education. Texas was an exception, where both public and private health-care providers were rated as "very interested". "Fear of other providers" and "capturing market share" are perceived as key drivers in the private health-care industry's interest in telemedicine. On the other hand, the perceived relatively lower interest on the public health-care providers part was driven by perceptions of prohibitive cost and lack of demand for telemedicine. Cost and established referral patterns are seen as negative influences on the interest of public health care as were startup and operational costs. On the positive side, "keeping up with advanced technology" and "providing value added service" are seen as important factors.

Recommended Roles for Key Players in the Development and Implementation of Statewide Telemedicine Vision

Governors need to consider the stakeholders in their states and consider the strengths and weaknesses they bring to the table when designing a process that will develop a statewide telemedicine vision. The following box lists the potential roles for the major telemedicine interests in each state based on the WGA survey results.

Organizing Frameworks

In states that have already undertaken a telemedicine planning initiative, various means have been employed to promote the use of telemedicine to provide health-related services and education. These include helping to establish public/private consortia, convening task forces, and working on broader policy and infrastructure issues. Clearly, there is not one best way, but a variety of state efforts are set forth below.

Consortia

The Alaska Telemedicine Project (ATP) was founded in 1994 by the University of Alaska Anchorage, Providence Health System in Alaska, and Alascom, Inc. (now AT&T Alascom). The project now has more than 45 members statewide. The ATP web site traffic increased by over 600% in just two months, with "hits" coming from over 30 countries. The communication system currently has over 1,600 users. Both networks are designed to provide, free of charge for a two-year period, access to medical and health-care information, and peer-to-peer communication designed to breakdown "professional isolation," the single most cited reason for the high turnover of health-care providers in rural Alaska.

The New Mexico Health Information Alliance (HIA) has been operating since 1995. The HIA, composed of public and private health-care sectors and representatives of the National Laboratories, was established to facilitate the application of information technology in health care. Its first responsibility is to develop a plan for and to implement a statewide, integrated health-data network. In Montana, private sector leaders have formed the Health Care Telecommunications Alliance, and Utah has a public/private Telemedicine Network and a Telemedicine Interest Group with over 100 members.

Task Forces/Statewide Conferences

In Hawaii, a Governor's Task Force on Health Tourism has been established to facilitate the development of health industry promotion. A component of this effort has been in the area of promoting telemedicine. The state also holds an annual telemedicine conference. Wyoming Governor Jim Geringer appointed the Governor's Telemedicine Steering Committee in the summer of 1997 to study and make recommendations to enhance and expand the utilization of telemedicine in the state. North Dakota Governor Edward T. Schafer has appointed a steering committee on telemedicine activities in North Dakota that is chaired by the State Health Officer. A statewide conference on telemedicine was an outgrowth of that committee's work.

In November, 1993, the South Dakota Telemedicine Task Force was appointed to: (1) assess how the state's health-care needs can be addressed by telemedicine; (2) demonstrate clinical telemedicine applications and evaluate their effectiveness; and, (3) create a plan for the development, implementation, and operation of a statewide telemedicine program. The task force of health-care providers, insurers, educators and state officials developed the Telemedicine Initiative which serves as the foundation for implementation of telemedicine in South Dakota.

The Utah Governor's Health Policy Commission has created a technical advisory group to study telemedicine. This should lead to a state strategic plan and possibly legislation and funding. In addition, there is a telemedicine billing task force working on billing and reimbursement issues that focuses on developing a uniform billing system for the state. In addition, a telehealth technical coordinating group assists sites with applying for federal universal service discounts and coordinates services among the several telecommunications exchange carriers.

Strategic Planning

The Nebraska Health and Human Services Department has begun a Strategic Planning Committee to give recommendations to the Department regarding the use of telecommunications in all facets of its work.

A state funded, strategic-planning process was completed in September of 1996 for the New Mexico Health Data Systems (HDS), an Internet-based integrated system which focuses on connectivity to health data. Initial applications are being designed and implemented with the technical assistance of Los Alamos National Laboratory. An independent public/private entity is planned to govern and operate the HDS and develop future applications.

Texas has integrated its telemedicine planning into its statewide telecommunications planning process. The Department of Information Resources produces a biennial strategic plan and the Telecommunications Planning Group works out system configurations, policies, standards, etc. including telemedicine applications. In addition, in 1996, the Texas Telemedicine Strategic Planning Project was formed to look for better ways to coordinate various telemedicine activities in the state.

State Approaches for Encouraging Telemedicine

Colorado, Idaho, and Oregon did not report any specific state approach.

1= non-state led consortia developed telemedicine recommendations

2 = developing statewide telemedicine institute

3 = as part of larger telecommunications planning

ATP-Alaska Telemedicine Project

MHTA-Montana Health Care Telecommunications Alliance

HIA-New Mexico Health Information Alliance

TIG/UTN-Utah Telemedicine Interest Group, Utah Telemedicine Network

WSBH-Washington State Board of Health 1997 Report, and Governor's Telecommunication Policy Coordination Task Force, 1994

WHIE-Wyoming Health Information Exchange

Network Improvement

Still other states focus their strategy primarily on promoting improvement and development of the entire telecommunications infrastructure for all uses, including telemedicine. Examples include Wyoming's leased Statewide Data Network which provides all of the telecommunication services for the Wyoming Compressed Video Network and South Dakota's policy of promoting use of ISDN lines and open architecture for telecommunications systems. Arizona's Project EAGLE (Education and Government Linking Electronically) seeks to leverage the combined telecommunications buying power of state agencies, the universities and the community colleges to facilitate the creation of an integrated statewide telecommunications network. This network, capable of supporting the transmission of voice, data, graphical and video images, will be privately owned and operated with the State of Arizona (through a multi-jurisdictional management council) serving as a contract manager and anchor tenant.

Integration of Telemedicine and Statewide Telecommunications Systems

Most states have not yet integrated telemedicine applications into the statewide telecommunications network planning process. Alaska and Texas are the only states to formally look at telemedicine as part of the entire telecommunications infrastructure. Alaska empaneled a telemedicine task force as part of its statewide telecommunications strategic planning process.

Other states have taken smaller steps toward integration. For example, in North Dakota representatives of the state telecommunications network, private telecommunications providers, and members of state infrastructure committee are involved in the state telemedicine steering committee. Similarly, the University of Utah telemedicine outreach specialist sits on the Utah Telecommunications Committee and the Utah Wide Area Network design team.

Even fewer states have taken steps to integrate public and private telecommunications networks for the purpose of providing health-related services and education. In fact, in at least one state (Texas), the state is prohibited by law from letting private entities use the statewide consolidated telecommunications network. Exceptions are varied and as follows:

The Wyoming Compressed Video Network is available statewide for education, state government and private industry for education, training and meetings. South Dakota's network is also available to the public.

Alaska has shared its microwave network and two way radio systems with local government and the private sector for select emergency medical and other targeted uses. In a similar vein, New Mexico issued a request for proposals to share its radio network with other users, and that could conceivably include health-related services and education.

Nebraska has connected its network for telemedicine purposes with private telecommunications networks in Kansas, Wyoming, Colorado, Montana, and Iowa.

In Utah the state Information Technology Services agency has a contract with USWest to provide discounted T1 connections.

Most states have not attempted to interconnect with another state's telecommunications network for the purpose of providing interstate health-related services or education. However, every state survey respondent indicated an interest in doing so. At least two states, Hawaii and Alaska are looking internationally as they plan the development of their telemedicine networks and applications. The domestic state examples of interstate interconnection focus primarily on health education and include:

Colorado and Wyoming - Mountain and Plains Partnership focuses on telehealth education for mid-level providers (Nurse Practitioners, Physicians Assistants, and Certified Nurse Midwives) using both video and the Internet.Colorado - State video network (CIVICS) connected to sites on the state's eastern plains and in Nebraska and Kansas via the High Plains Rural Health Network for delivery of educational courses.Montana - Private sector telemedicine interconnection for clinical consultation.South Dakota - Rural Development Telecommunications Network connects interstate.Utah - Tested interconnections with Montana and Wyoming but not yet used for telemedicine.Wyoming - Connected its compressed video to other states for education and health- related education and policy meetings.WWAMI - Washington, Wyoming, Alaska, Montana, and Idaho health education network sponsored by University of Washington.

Funding for Telemedicine

Not all states provided data on current funding for telemedicine activities. From those that did, it is clear that telemedicine funding is a catch-as-catch can proposition coming from a mixture of federal, state, private, and other sources. The box below details the components of 1997 fiscal year funding for state telemedicine initiatives.

FY 1997 Estimated Funding Amounts and Sources for Telemedicine/Telehealth Activities

1. $1,300,000 for six years

2. Legislature created the Telecommunications Infrastructure Fund in 1995. The fund was to generate $150 million/year but court rulings on the funding mechanism reduced that to $95 million/year with only $15 million available for telemedicine.

IV. SNAPSHOT OF WESTERN STATE TELEMEDICINE ACTIVITIES/SERVICES

To develop the snapshot of activities in each state, respondents were surveyed about their current and planned telemedicine networks and services. They were also asked about the relationship of the state's telemedicine and telecommunications networks with other entities including the private sector, higher education, and health and human services organizations. This information was then supplemented through additional individual interviews and through information obtained in other publications.

ALASKA

Telemedicine is very important in the State of Alaska as illustrated by the fact that of the 22 non-profit hospitals in the state, all of them use telemedicine for everything ranging from teleradiology, to consults, to medical database access. The same can be said for the state's one private hospital and its 10 nonprofit physician and 18 mid-level practitioner clinics. Even the 23 public health centers in the state perform consults using telemedicine.

Planned and future telemedicine initiatives are occurring in the following three major arenas:

1) The Applied Sciences Laboratory of the University of Alaska Anchorage (UAA) is implementing and evaluating narrow bandwidth telemedicine applications in rural Alaska under a $2 million contract with the National Library of Medicine. The UAA School of Nursing has been using the Alaska telehealth system for the last two years to provide graduate level education to nurse practitioners in rural Alaska. The first class of "telehealth nurse practitioners" was graduated in May 1997.

2) The Alaska Native Health Board is a subcontractor to UAA for the National Library of Medicine contract. They are participating in the development and implementation of a telemedicine workstation system that will be deployed in four rural regional hospitals, 26 village clinics and the Alaska Native Medical Center.

3) As a founding member of Alaska Telemedicine Project previously discussed, Providence Health Systems is implementing telecommunications and information technology applications and technologies to accommodate clinical, administrative and educational health-care services to rural Alaska. A nine-site network was recently established connecting rural communities to the Radiology Department at Providence Alaska Medical Center. An eight-site extension of the Alaska Telehealth System will be fully operational in June. These networks will be used for clinical consults and continuing medical education.

There are several major telemedicine initiatives in Arizona. In 1996, a multidisciplinary clinical Arizona Telemedicine Program was established by the state legislature at the state's sole college of medicine, the University of Arizona Health Sciences Center in Tucson. The Program includes several components: (1) the Arizona Rural Telemedicine Network; (2) the Arizona Telemedicine Assessment Center; (3) the Arizona Telemedicine Training Center; and, (4) Project Nightingale.

The Arizona Rural Telemedicine Network is providing telemedicine services and distance education over a dedicated TI/ATM network. Service offerings vary from site to site and include 25 subspecialty telemedicine services, telepsychiatry, teleradiology and telepathology. Currently, the Network links the College of Medicine faculty service-providers to 11 rural health-care facilities including hospitals, an extended care facility, a prison and a community health center. Among the participating agencies are the Arizona Department of Corrections, the Indian Health Service, and the Department of Veterans Affairs. The Network has received state funding and federal grants.

The Arizona Telemedicine Assessment Center is involved in studies of various telecommunications systems, telemedicine appliances, and novel potential applications. Current research includes development of PACS systems, evaluation of digital cameras, and development of robotically-controlled telemedicine equipment. Several dozen faculty members are involved. The Arizona Training Center brings health-care professionals onsite for in-depth training on the use of telemedicine equipment, protocols, forms, and evaluation methods. It also provides current updates in the use of telemedicine locally, nationally, and internationally. The Center held three training conferences in 1997 with an average of 25 attendees, and it is used by vendors to demonstrate their products to health-care professionals. Project Nightingale was established as a statewide effort to create a multi-agency, health-care telecommunications consortium. Telecommunication tariffs in the state are extremely high and it is felt that the sharing of infrastructure is vital to the continued success of telemedicine.

Another telemedicine network, the Northern Arizona Regional Behavioral Health Authority, delivers mental health services over a private T1-based interactive video teleconferencing system. Currently, 12 sites have been installed. Case accrual rates have been unusually high as mental-health services are brought to underserved areas. The program is funded by the Arizona Department of Health Services.

CALIFORNIA

As of late 1996, 23 of 74 rural hospitals in the state responded to a survey and confirmed their use of telemedicine. Radiology is the overwhelming clinical use by these facilities. Thirty hospitals and university medical centers confirmed their telemedicine usage at that time. Again radiology was the predominant use with other uses including fetal monitoring, dermatology, neurosurgery, and continuing education. Various California governmental entities are piloting telemedicine projects to determine its benefits to their operations. With a National Library of Medicine grant, the University of California, San Francisco is testing a network using neuro-images and is using the network to evaluate high-performance teleimaging for breast imaging. A Western Consortium for Public Health is linking 11 rural counties for public-health information using technologies such as video conferencing and pen-based computers. Other telemedicine activities are taking place in the Riverside County Department of Mental Health, the California Department of Health Services, and the California Department of Corrections.

In an effort to expand telemedicine use, California enacted comprehensive legislation in 1996 to address the legal and policy barriers to the practice. Included in the Telemedicine Development Act of 1996 is a requirement that private health insurance and managed-care plans integrate telemedicine into their existing reimbursement policies and procedures. Also addressed are the telemedicine barriers of confidentiality, informed patient consent, and physician licensure.

COLORADO

There are several well-established telemedicine efforts in Colorado, and an unknown but rapidly increasing number of sites and practitioners who link to clinical services and educational resources and programs through the Internet. The Colorado Area Health Education Program, for example, operates the Mountain and Plains Partnership, a regional educational system for mid-level health professionals over the Internet, providing interactive video/computer instruction to approximately 100 "TeleLearning Center" sites in Colorado, Wyoming, Arizona, and New Mexico. One hundred fifty sites are projected by the period 1998-1999.

The University of Colorado Health Sciences Center (UCHSC) is participating in a telemedicine/teleconferencing consortium of 18 hospitals called "Health Care Colorado." The UCHSC maintains telemedicine links to four hospitals and outlying portions of its own campus in Denver, and links to seven hospitals across the state. UCHSC also provides services to four COAHEC interactive video teleconference sites (six sites projected for 1998), to other sites on the State CIVICs Network, and to other networks such as the Wyoming interactive video network and the High Plains Rural Health Network.

Denver Health Medical Center recently installed a telemedicine link to Routt Memorial Hospital in Steamboat Springs with links to both the emergency room and operating room for access to its Level I trauma center consulting expertise. Denver Health is also collaborating with the UCHSC to provide telemedicine support to a Department of Corrections site at Limon over the State CIVICs Network and they expect to expand these services to other correctional facilities throughout the state in 1998.

The private sector is also active with telemedicine in the state with Kaiser Permanente operating a network of 15 clinical sites and five business office sites for clinical consults, staff and patient education, and business teleconferencing. The High Plains Rural Health Network, based in eastern Colorado, includes in its membership 18 hospitals; three clinics; and two CIVICs partner sites; and a large, medically underserved region in the northeast part of the state. High Plains also links to three sites in Nebraska and Kansas. High Plains provides interactive video conferencing to deliver specialty health care and continuing education, and supports a rural residency program between Greeley and Wray, Colorado. Centura Health operates the Colorado Telhealth Network (CTN), a telemedicine network linking 21 health-care sites in Colorado: nine rural hospitals, three rural clinics, four urban tertiary hospitals, four urban primary/secondary hospitals, and a support center. CTN provides clinical telemedicine services in a variety of specialty areas and is also used for distance education.

There is also at least one site which is managed by a proprietary service provider. An out-of-state, commercial vendor, Medical Development International of Chantilly, Virginia, operates two correctional telemedicine sites for Arapahoe County, Colorado.

HAWAII

In January of 1998, the Governor launched a statewide and comprehensive telemedicine network. The network will have as its base the public Hawaii Health Systems Corporation that operates a 3,000-employee, 12-hospital, 1,200-bed acute, long-term and rural health-care system on every Hawaiian island. These facilities will be linked with 16 other rural medical centers making every hospital and clinic in the state able to use telemedicine for diagnosis, consults and continuing education. Three Hawaiian telecommunications companies are also partners in this effort.

The Governor has invited world-class medical service providers to the state in order to establish it as a medical center for the Asia-Pacific region. As part of this initiative there are a number of pilot projects and planning processes including: Queens Medical Center's pilot project to use teleconsultation in emergency room services between Molokai General and Queens Hospital; the U.S. Public Health Service and the Pacific Island Health Officers Association within the School of Public Health among others have developed a project to implement electronic mail systems in health clinics and hospitals in the Western Pacific Islands Region via satellite network; and, a cancer center under development will have a telemedicine link with Hilo's non-profit Family Practice Center, the University's School of Medicine and, Tripler Army Medical Center.

Hawaii also works closely with federal agencies and the military that are involved in telemedicine development and support. The state does not provide telecommunications services to the private sector, but it works closely with them to resolve policy issues, to encourage the appropriate use of technology, and to develop business. Finally, the University's Medical School works independently with private and public sector partners on various telemedicine projects.

IDAHO

Only a few of the 50 hospitals in Idaho are currently using telemedicine for direct patient services. The North Idaho Rural Health Consortium (NIRHC), which consists of the five community hospitals of the five northern counties of Idaho, has developed an integrated health-care delivery telemedicine system for rural communities. In 1995, the NIRHC received funding from the Rural Utilities Service to develop the North Idaho Community Education and Health Information Network. This interactive-video network links the five hospitals and North Idaho College together. This network has been used to provide continuing medical and nursing education to the members since December 1996. Radiology, and emergency medicine specialists are currently available on an on-call capacity and there are plans to expand the network into mental health services.

Teton Valley Hospital in Driggs, Idaho, is a partner with the Washington, Wyoming, Alaska, Montana, and Idaho Telemedicine Network which links four remote rural communities throughout the Northwest to the University of Washington Medical Center. Additional users of telemedicine are St. Lukes Regional Medical Center and St. Alphonsus Regional Medical Center in Boise. The Idaho Office of Rural Health is currently working with the Idaho Hospital Association to develop a survey to assess the extent of activity, barriers, and opportunities for telemedicine in the state.

MONTANA

Montana has seven separate video telemedicine networks providing services to 34 rural hospitals and clinics. Six of the video networks are based in private non-profit hospitals in secondary or tertiary medical centers. The seventh network is based at a university medical center. For example, the Eastern Montana Telemedicine Network/Deaconess-Billings Clinic Health Systems uses two-way interactive video conferencing to deliver specialty health care to ten isolated communities in Eastern Montana. The Southwest Montana Telepsychiatry Network based at St. Peters's Community Hospital Foundation in Helena uses interactive compressed video to improve access and quality of mental health services and education in a twelve-county region. In addition to video consultations, each of the seven Montana networks provides teleradiology and still image transmission, as well as distance education activities and video conferencing for administrative meetings. At least three other computer-modem networks provide teleradiology, still image transmission, and e-mail consultations.

Although each network is administratively independent, each network can be connected to the others, and to the state's MetNet educational video network for cooperative activities. All networks are actively expanding both the numbers of sites served and services offered. While each telemedicine network was initially developed to provide clinical consultation for medical providers, most of them have expanded, providing mental health services and distance education. Partners in these efforts include rural clinics, rural and urban hospitals, mental health centers, residential treatment facilities, and law enforcement and judicial agencies. By recognizing the reality that medical consultations alone may not sustain telemedicine networks, Montana's projects have broadened their support partnerships to increase their viability.

NEBRASKA

Five non-profit hospitals use telemedicine in Nebraska for everything from telepsychiatry to medical and video consultations, and medical/patient education. This level of telemedicine use should increase in the state in the next few years because the Department of Health and Human Services recently established a strategic planning committee to give it direction and recommendations regarding the use of telecommunications in all facets of its work. One present use of telemedicine is by the Mid-Nebraska Telemedicine Network in Kearney which has established a consortium of six rural hospitals within Good Samaritan Health Systems. The system provides video-conferencing and store-and-forward capabilities to serve approximately 90 patients each month.

The Division of Information Services of the Nebraska Department of Administrative Services works closely with Health and Human Services as they deploy client-server based technology. The Division also works with University of Nebraska Medical Center and the Nebraska Hospitals and Health Care Systems Association to share the state's network. In addition, the Division also provides funding to the association's Telecommunications Project to identify the best telemedicine models for small hospitals.

NEVADA

All 13 of the state's non-profit hospitals use telemedicine networks. Teleradiology is used by all of them with uses coming also in the form of telepsychiatry, telercardiology, medical education and consultations.

The University of Nevada School of Medicine is the center of telemedicine activity in the state. The School of Medicine is community-based, using and depending upon volunteer community faculty for training of medical students and residents. The School of Medicine supports rural providers with an Office of Rural Health, Area Health Education Center, and other programs. Three units of the school currently have or will have linkage to six additional rural communities through the leased network of the university system. The medical school works closely with the state health division and other agencies. A developing relationship for telemedicine services in conjunction with the Division of Mental Health and Mental Retardation is under negotiation. A close and long-standing relationship with Indian Health Services provides continuing education, learning resources, medical student rotations, and other services to tribal members in Nevada.

NEW MEXICO

Only a few of the 38 hospitals in New Mexico actively use telemedicine for direct patient services. Twelve of them use Internet access for medical database research. This sparsity of telemedicine activity is likely to change in the coming years. By legislation in 1994, the state established the Health Information Alliance (HIA) to facilitate the application of information technology in health care with its first responsibility being the development and implementation of a statewide integrated health data network. HIA is composed of the private and public health-care sectors along with representatives of the Los Alamos and Sandia national laboratories. In addition, primary plans have been developed for creating a telemedicine video link for telepsychiatry, training and continuing education between the rural Las Vegas Medical Center and the University of New Mexico Health Sciences Center (UNMHSC).

The Northern New Mexico Telemedicine Project is working to develop and implement a "virtual" primary care medical record using a distributed database architecture. The system will connect rural hospitals, primary care clinics, and public health facilities to enable authorized access to patient records, even when a clinic or facility is closed, to enhance coordination and quality of care. Finally, discussions have begun regarding the creation of a telemedicine link between the Eastern New Mexico Medical Center in Roswell and the UNMHSC for medical consults, teleradiology, telecardiology, and medical resident support.

NORTH DAKOTA

Telemedicine networks in North Dakota are extensive and are expected to continue to grow. While one public hospital uses telemedicine technology, 46 private hospitals use it, primarily for medical consultations or education. Sixty-four physician clinics and 75 mid-level practitioner clinics use telemedicine technology for a variety of purposes. Major projects underway include linking rural health-care facilities throughout the state with regional medical centers. Additional users are Indian Health Services, mental health clinics, physicians' homes, and nursing homes throughout the state.

The Med Star program at the University of North Dakota links the school to hospitals throughout the state via an audio-video network. Through this network, physicians, nurses, physical therapists and any other health-care professionals can take a wide variety of continuing education courses taught by professors in the UND School of Medicine. Nursing homes and other elderly care centers are another logical application for telemedicine. Good Samaritan Nursing Centers are conducting a pilot project in eight rural North Dakota communities, connecting their facilities to regional medical centers for consultative and intermittent care of patients.

The state works closely with higher education institutions that have shared telecommunication networks with the state for many years. The state's Information Services Division provides

circuits as part of a statewide distance education project that can connect universities, tribal colleges and K-12 schools. Recent legislation called on the state to develop a five-year strategic plan for information technology with these higher education institutions, including the University of North Dakota Medical School.

OREGON

There is a statewide telecommunications network in the state that is only available to government agencies. However, the Oregon Telecommunications Forum Council is developing a strategy for improving access to affordable telecommunications services for all citizens. There are, nonetheless, a number of telemedicine projects and activities currently taking place in Oregon.

The Central Oregon Network based at St. Charles Medical Center in Bend, has received a Rural Utilities Service grant to provide increased access to specialty care, data sharing and community programming using a T-1 line. RODEO-NET, through the Eastern Oregon Human Services Consortium, is conducting regional collaborative mental health activities in remote areas of Eastern Oregon. Also in Eastern Oregon, the Northeastern Oregon Teleradiology Network in Grande Ronde is transmitting x-rays and ultrasound images between two community hospitals and Oregon Health Sciences University (OHSU) in Portland. A National Library of Medicine contract with OHSU will be wrapping up in June 1998 after a four-year project to develop a low-cost teledermatology system. Clinics in five rural towns in Oregon were provided with a low-cost store-and-forward units for consultations with dermatologists in Portland.

The Telemedicine Research Center based in Portland sponsors the Telemedicine Information Exchange web site and is also developing evaluation software for telemedicine programs. The Association of Telemedicine Service Providers, a new telemedicine membership organization, is also based in Portland.

SOUTH DAKOTA

Telemedicine is used by the community hospitals in the State of South Dakota for a variety of services. Applications include teleradiology, cardiology, psychiatry, and medical consults. An estimated 35 facilities provide or receive medical education. Computer linked intranets are being proposed for clinical and administrative linkages. The largest network in the state, the Dakota Health Network, involves 21 hospitals, 14 clinics, and 11 long-term care facilities across 11 counties in South and North Dakota.

The South Dakota Department of Health was under contract with the private health-care providers participating in the Rural Telemedicine Grant Program administered by the Federal Office of Rural Health Policy. Three separate networks, comprised of a hub site (one of three urban hospitals) and their respective spoke sites, are demonstrating teleradiology and interactive telemedicine applications. The South Dakota Department of Health coordinated the evaluation efforts of these various applications.

TEXAS

In December of 1996 at least 49 telemedicine networks or projects were identified. The major clinical applications used by the 27 projects that responded to inquiries were specialty consultations, radiology, and emergency service. Nearly all of the projects also reported some type of educational use. Texas telemedicine use will likely expand rapidly in the coming years. The Texas legislature has established a goal of providing access to health care to rural and underserved areas. The Telecommunications Infrastructure Fund of $150 million a year for 10 years has been established to fund telemedicine, distance learning, and library applications. Many of the universities and health-science centers in the state have plans to expand the scope and coverage of their video networks to serve additional health-care providers with telemedicine applications.

The state's General Services Commission meets with university medical centers both individually and through the Telecommunications Planning Group to determine their immediate and long-term needs for telecommunication services. Additionally, the health and human services agencies have formed a governing board to coordinate and manage their joint telecommunications requirements. The statewide consolidated network cannot be provided to the private sector, but it is provided to state agencies, public institutions of higher education, and political subdivisions. As mandated by the legislature, however, universities often use the state's network to support private health-care initiatives.

UTAH

Six public and three private hospitals in the state use telemedicine. The technology is used for teleradiology, telecardiology, medical consultations and education and for access to medical databases. Grants have been applied for to link two rural health departments in the state specifically to reach children with special health-care needs and to add approximately six additional sites to Utah telemedicine networks. The Shriners Hospital is also developing a link to the Utah Telemedicine Network and to its out-of-state clinics.

Utah's Telemedicine Network is managed by the Telemedicine Outreach Program at the University of Utah. The Network provides continuing medical education, information technology training and library resources. The Network is also used by Utah Area Health Education Center to service rural areas of the state.

There is a significant partnership between public and higher education in Utah that includes University Hospital. The Utah Education Network provides data services to approximately 560 sites and higher education institutions in the state.

Utah recently received three federal telemedicine related grants. A physician's assistant in Cedar City received a grant to develop the concept of a mobile telemedicine clinic; Weber State College was awarded a grant to install video conferencing units in five rural hospitals for training nurses and radiology technicians; and the University of Utah received a grant to install video-conferencing units in two local health department offices to provide services to children with special health-care needs.

WASHINGTON

Telemedicine is progressing impressively in Washington state, and it will continue to grow in the coming years. At least 22 of the 94 private and public hospitals have some type of telemedicine activity, and many of those that do not have current activities anticipate using telemedicine in the future. There are 15 telemedicine networks in the state with an average of 10 facilities connected over each network. Many of these networks reach out-of-state populations. The bulk of the use on these networks is for teleradiology and other forms of telemedicine.

One of the major networks in the state is the Washington, Wyoming, Alaska, Montana and Idaho Rural Telemedicine Network (WWAMI) that connects a total of six remote rural counties in those states with the University of Washington School of Medicine. Using PC-based desktop units for video-conferencing and digital image transmission, WWAMI facilitates both real-time and store and forward communications. Consultations are available in a wide range of specialty areas including dermatology, orthopedics, radiology, psychiatry and pediatrics.

WYOMING

All hospitals in the state use telemedicine for one purpose or another with the main use being teleradiology. The telemedicine program between Wyoming Medical Center in Casper and Converse County Memorial Hospital in Douglas hopes to expand telemedicine services to two, small community hospitals and a community clinic. In addition, the Wyoming Department of Education is entertaining proposals for the improvement of the statewide telecommunications infrastructure for education that, once implemented, will benefit the entire health-care system.

Wyoming has always maintained a close working relationship with the University of Wyoming on information technology and telecommunications. The Wyoming Compressed Video Network started as a joint project to improve the distance learning program and as a methodology to lessen the need for travel. The network operates on the leased statewide data network and has grown from eight to 34 sites across Wyoming. A significant amount of network time is dedicated to education, including courses for nurses and other mid-level professionals. The College of Health Sciences at the University has also joined the Washington, Wyoming, Alaska, Montana and Idaho Rural Telemedicine Network, which operates a telemedicine network originating from the University of Washington.

Wyoming works very closely with its private-sector health community. The State's Department of Health has entered into a private/public partnership to establish the Wyoming Health and Information Exchange (WHIE). The WHIE will serve as a clearinghouse for all health-care data in the state. The data will be collected as a by-product of billing insurance claims and collecting hospital discharge data. The State's Chief Information Officer also maintains a close relationship with all health-care providers and associations in the state, and he works with them on all grant applications they submit for telecommunications projects.

V. STATE TELECOMMUNICATIONS NETWORKS AND INFRASTRUCTURE

Introduction

Since the break-up of the Bell System in the mid 1980s, states have taken advantage of the flexibility and opportunities brought on by divestiture to improve their telecommunications capabilities. By leveraging the fact that they represent one of the largest buyers and users of telecommunications services and equipment, states have played a key role in encouraging the private sector to invest in building a more advanced public telecommunications infrastructure.

Each state has established a central organization that procures and manages telecommunications resources for state government. In many instances, these organizations provide services for multiple end-users, including state agencies, local and county governments, public health-care facilities, public schools and public libraries. State telecommunications organizations are designed to save taxpayer money through the aggregated procurement and operation of telecommunications facilities and services on a scale far larger than anything possible from individual government entities. Typically operated on a cost recovery basis, meaning they receive little or no direct state appropriations, these organizations simply pass on the costs of the services provided proportionately to the end-user.

Within this operating structure, states provide a variety of telecommunications services including local and long-distance voice communications, data networking, video conferencing and Internet access. These services are generally delivered through a combination of state-owned and leased equipment and facilities offered through the public network by the private sector.

The scope and configuration of each state's telecommunications infrastructure varies widely based on such factors as population, geography, and business and political climate. And while each state has taken a slightly different approach to providing voice, data and video services to end-users, the majority rely heavily on leasing network facilities and services from the private sector rather than investing in state-owned and operated systems. In fact, more than 75 percent of Western states' telecommunications network infrastructure is leased. This figure is consistent with data collected since 1991 by the National Association of State Telecommunications Directors that reflects a steady movement away from state-owned systems in favor of leveraging the advanced capabilities of the public switched network offered by the private sector.

Western State Telecommunications Activities

Government organizations have traditionally not fared well when compared to their private sector counterparts in the adoption and application of technology to provide better, faster and more cost-efficient products and services to customers. While the wheels of change have been slow, states have realized significant gains in recent years in the use of technology as a tool to improve service delivery. These gains have come despite increasing financial pressures to do more with less and are a result of state policy makers and administrators recognizing the need to streamline government services and emphasize quality, customer service, and outcomes rather than process.

The telecommunications infrastructure in Western states has grown to meet the changing needs of government users and citizens alike. In addition to providing traditional voice services such as local dial tone and toll calling, a majority of states now offer a range of voice applications including toll-free services, voice processing, paging, pay phone/inmate calling, calling cards and cellular service. A number of states also currently provide, or plan to provide in the next two years, 900 services, two-way radio systems, hearing impaired relay services and computer-telephony integration.

The shift away from mainframe applications to desktop business applications, coupled with the explosion of the Internet, has profoundly impacted state government operations. The proliferation of local and wide-area networking and the incredible volume of data that is shared across these networks have created a demand for better technology and faster methods of transporting information. Western states provide, or plan to provide in the near future, the very latest in data transmission technologies such as ATM, FDDI and Frame Relay along with providing access to the Internet for e-mail and world wide web information. Recent advances in video technology has not escaped state government. Most Western states are quickly adopting video conferencing for such applications as distance education, inmate arraignments, administrative conferencing and, of course, telemedicine.

Key Findings & Conclusions

Strategic/Planned Telecommunications Activities

The rapid pace of technological advances has compelled many states to initiate long-range, strategic planning processes to determine how and where to spend their telecommunications resources. These initiatives often involve a wide range of stakeholders including the governor's office, legislature, various state agencies, public colleges and universities, and representatives from the private sector. The results of these efforts typically include a strategic direction for the state to follow for the next three to five years as well as a framework on which to maintain and enhance the state's telecommunications investment.

Examples of Strategic, Long-Range Telecommunications Planning

Arizona -- through Project EAGLE (Education and Government Linking Electronically) seeks to leverage the combined telecommunications buying power of state agencies, the universities, and the community colleges to facilitate the creation of an integrated statewide telecommunications network. This network will be privately owned and operated, with the State of Arizona serving as a contract manager and anchor tenant.

South Dakota - passed legislation in 1997 to develop an "infrastructure that meets the advanced communications needs of the state's citizens and its communities of interest including schools, medical facilities, businesses and all levels of government."

Texas - long-range strategic planning for telecommunications services is vested in two groups: the Department of Information Resources, which prepares and issues a biennial strategic plan for the use of telecommunications technologies; and the Telecommunications Planning Group, which is responsible for developing network configurations, operational plans and policies, and technical specifications.

Utah - long-term strategic plan for telecommunications is to develop a single, shared optimum network for voice, video, data and wireless communications comprised of 18 strategic hub sites located throughout the state linked by high-speed fiber optic facilities.

Washington - passed legislation in 1996 that provides $42 million for establishment of K-12 education telecommunications network. Governor's Telecommunications Policy Coordination Task Force has made a series of recommendations designed to promote the deployment of advanced telecommunications services while ensuring the continuation of affordable basic phone service in rural areas.

Wyoming -- signed a contract with US WEST Communications which will design and construct of a statewide, high-speed data and video network to connect all Wyoming public schools and give communities capability for telemedicine, economic development, and community outreach applications.

APPENDIX ONE

Glossary of Telecommunications Technology Acronyms

dthied@quest.state.wy.us

Page last updated 10/10/1999