telemedicine and inpatient ambulatory care for rural alaska
Post on 20-Mar-2017
153 Views
Preview:
TRANSCRIPT
Running head: TELEMEDICINE & INPATIENT/AMBULATORY CARE 1
Telemedicine & Inpatient/Ambulatory Care in Rural Alaska
Patrick Williams
Saint Joseph’s University
TELEMEDICINE & INPATIENT/AMBULATORY CARE 2
Abstract
US Health care is organized with a mixed system, changing continuously to fit the needs of care
worldwide. Within this continuum lies inpatient and ambulatory care. Both ambulatory and
inpatient care are utilized to fit the needs of patients, with the best health outcome in mind.
Scientific developments from both medical technology and the pharmaceutical industry have led
to changes in each care network. Health care facilities including critical access hospitals and
rural outpatient networks are finding it easier to offer high level treatment because of discoveries
in applied sciences and information technology. According to Eron (2010), information
technology regarding telemedical use between patient and provider is the future of health care
(p.224). Telemedicine and remote health offer a broad continuum of medical practice within both
ambulatory and inpatient care settings (Clark et al., 2010, p. 261). This research paper will assess
Telemedicine and its effect on ambulatory and inpatient care from the perspective of both rural
Alaskan based hospitals and outpatient networks.
TELEMEDICINE & INPATIENT/AMBULATORY CARE 3
Telemedicine & Inpatient/Ambulatory Care in Rural Alaska
Health care outreach is broad, serving different ethnic groups and cultures across the
world. Uniquely, US health care functions with no governing agency. Currently US health care
functions through a mixture of market and social justice systems (Budetti, 2008, p. 92).Within
this health care mixture is ambulatory/outpatient and inpatient care. By definition ambulatory
care is treatment provided to patients not required to stay in an overnight in a health care facility.
Outpatient care is usually performed in hospital or clinic setting (Shi & Singh, 2013, p.161). In
contrast, inpatient care is a defined as an overnight stay in a health care facility (Shi & Singh,
2013, p.185). Determining whether or not a patient requires inpatient or outpatient care upon
health care staff judgment for positive health outcomes (White & Glazier, 2011, p.58). Most
non-rural health care organizations consist of inpatient and outpatient care within one setting.
Providing health care in rural locations can be a challenge. Many rural communities exist
without large hospitals and specialty health care. The vastness of Alaska and its complexity as a
state creates issues within many remote locations. According to Choudhury et al., 2008, Alaska’s
population density measures one person per mile (p.2). This Alaskan frontier has created
challenges for administration of health care services for many rural outlying communities
(Roberts, 2011, p.10). These barriers for Alaska based communities include: accessibility,
acceptability and availability of services (Mohatt, et al., 2005). Health care institutions in Alaska
are required to utilize alternate routes for health care delivery for provision of appropriate care
for its residents.
Telemedicine
Medical technology is a complex, powerful and costly system that affects health care on
many levels (Williams, 2008, p.38). Medical professionals are trained different than ever before,
TELEMEDICINE & INPATIENT/AMBULATORY CARE 4
because of high level advances in both the medical technology. The fundamental reason why
medical technology changes the way health professionals practice medicine is high outcome and
result expectations by patients receiving the services (Shi & Singh, 2013, p.105). When result
expectations are high, medical professionals are required to provide detailed care by: staying
informed of latest developments/ advances in medicine, following expert clinical guidelines and
staying ahead of competitive pressure placed by newer technologies (Williams, 2008, p.35).
Health care delivery is an objective placed by many health care organizations seeking to increase
organizational strength by accessibility of services. The use of medical technology for health
service delivery is a popular practice for rural areas and isn’t an entirely new concept (Roberts,
2011, p.). Distance health service began in the early 1950’s, two way radios for physician
communication regarding medical terminology (Patrickoski, 2004, p.365). According to Clark et
al., 2010, any electronic device used to transmit clinical health service is considered E-Health, or
telemedicine (p. 261). Currently, telemedicine is a critical component of health care. Studies
reveal that every state has a telemedical program; most involving many outlying hospitals and
clinics (Shah, et al., 2013, p.200). The terms telemedicine, e-health and teletherapy coincide,
each accounting for electronic medical communication (Nelson, et. al., 2012, p.10). E-health
benefits rural communities by providing health care for individuals and groups considered
inaccessible through electronic communication with distant facilities and specialty physicians
(Roberts, 2011, p.10). Telemedicine originated in 1877, when physicians first used phones to
transfer medical advice. Alaska also was the first state to develop the first pilot telemedical
program in 1950. Under the establishment of the Indian Health Service (IHS), village doctors
communicated directly to community health aides for patient evaluations and care procedures.
Health aides monitored each patient and contacted physicians via radio for advice and care
TELEMEDICINE & INPATIENT/AMBULATORY CARE 5
related to the patient’s condition (Clark et al., 2010, p.261). Even with these accomplishments,
telemedicine wasn’t accepted nationwide as a beneficial health program. Pilot programs had little
effect because of two factors: absence of appropriate technology and financial instability/cost. It
wasn’t until the US Presidential Reagan administration of the 1980s that telemedicine/e-health
was widely accepted. During that time, telemedicine was used for military and disaster relief
purposes, allowing health care delivery networks across the globe (Clark et al., 2010, p.263).
With continued development of medical technology over the last two decades, applications of
electronic based health care have grown. Telemedicine is now benefiting rural areas by
utilization in: specialty care, patient consultations, remote monitoring and medical education
(Clark et al., 2010, p.263). Benefits of telemedical use include: reduced health care costs,
increased patient access to specialty providers, improved quality/continuity of care, faster/more
convenient treatment resulting in reduction of lost time/travel costs (Clark et al., 2010, p. 263).
This research paper will assess pilot telemedical programs and discuss their effect on rural
inpatient and ambulatory care of Alaska.
Ambulatory/outpatient networks
Use of electronic communication for ambulatory care is improving. Telemedicine is
affecting ambulatory care networks by improving decision-making, remote-sensing and
collaborative arrangements of providers (Clark et al., 2010, p.262). According to Eron (2010),
telemedicine is considered the future of outpatient health care (p.224). E-health can assist in
overcoming barriers linked to ambulatory care by decreasing health care costs and adding
specialty physician reach for limited locations (Eron, 2010, p.224). Rural locations are receiving
health care that was never thought possible through electronic devices (Nelson, et al., 2012,
TELEMEDICINE & INPATIENT/AMBULATORY CARE 6
p.10). Two rural ambulatory/outpatient care networks are provided: primary care telemedicine,
tele-behavioral health/tele-psychiatry.
Primary care. Primary care is defined as the foundation for outpatient services. Primary
care contains integrated accessible services accounting for the majority of personal health care
needs (Vanselow et al., 1995, p.192). Primary care is the largest sector of health care delivery in
the United States (Shi & Singh, 2013, p.).Meeting primary care needs for the growth in an aging
population is challenging for the US (Shah, et al., 2013, p.223). A shortage of primary care
providers and recent increases in the older adult population has both played a role in accessibility
and timeliness of services. Rural locations continue to face difficulties providing primary care
because of accessibility, acceptability and availability of services (Mohatt, et al,. 2005).
Telemedicine delivery offers timely, high quality patient centered health care by improving
quality of life for patients needing primary care services (Shah, et al., 2013, p.223). Rural
locations benefit from the ability to reach specialized primary care physicians not available in
their location. Primary care telemedical pilot programs are currently being evaluated for
increased utilization. The association of primary care and telemedicine has seen an increase in
research documentation and investigation over the past two decades. Many programs offer
exams for people who are cannot access health care on a routine basis. Evidence from pilot
programs reveal telemedicine gives patients a feeling of empowerment, and improves health
outcomes (Shah, et al., 2013, p.229). Veteran’s affairs in Oklahoma City, Oklahoma recently
researched telemedical primary care by examining quality and efficiency in rural locations
(Sorocco, 2013, p.350). The pilot program is considered a success. Patient health improvements
and data collection were shown within a 6 month time period. Documented improvements
include: physical strength, social functioning, decreased caregiver burden and compliance with
TELEMEDICINE & INPATIENT/AMBULATORY CARE 7
treatment programs (Sorocco, 2013, p. 352). A second pilot program, the Alaska Federal Health
Care Access Network (AFHCAN) gave research and projections for primary care via
telemedicine for rural Alaska communities (Patrickoksi, 2004, p. 370). The AFHCAN originated
in 1998 though US Department of Health and Human Services. This projects mission is to
improve health care for Alaskan natives by using sustainable telehealth systems. AFHCAN
generated over 235 sites linked by telehealth to primary care physicians, and improved the
overall health of Alaska natives (Patrickoski, 2004, p. 371). Programs like the AFHCAN
continue to help Alaska move toward an open system, where everyone has access to primary care
services. Studies reveal there are limitations associated with telemedicine and primary care.
Issues include technical problems associated with bandwidth capabilities, reimbursement from
3rd party sources and legal challenges for primary care (Shah, et al., 2013, p.229). Resolving
issues will ensure utilization of primary care telemedicine services. Programs like AFHCAN
work to limit barriers by bringing different organizations together to form coalitions. These
groups serve as AFHCAN project officers, to ensure compliance and limit barriers associated
with telemedicine projects. Project officers also carry out day to day management of primary
care telemedicine issues (Patrickoski, 2004. p. 371).
Tele-behavioral health. Behavioral/mental health is a significant issue in most locations.
The terms behavioral health and mental health can be used interchangeably. Mental health is
defined by the World Health Organization as psychological well-being, or the absence of a
mental disorder or illness (WHO, 2001, p.1). Behavioral health continues to be a significant
challenge in rural locations. It is estimated that nearly 60% of rural America is underserved
regarding mental health services (Roberts, et al., 2011, p.10). Communication between large
health organizations and rural locations is common to deliver behavioral health care service to
TELEMEDICINE & INPATIENT/AMBULATORY CARE 8
those without accessibility. Applications like two way Skype equipment offer new innovative
ways for accessibility (Nelson, et al., 2012, p.10). Outpatient behavioral health telemedicine can
involve screening, assessment, primary treatment and after-care. This application can also
provide accessible treatment for those who have barriers related to location, shame, guilt and
stigma (Nelson, et al., 2012, p.10). Pilot programs for behavioral health telemedicine originated
in Alaska during the 1950’s, utilizing health aides for communication between the patient and
physician (Clark et al., 2010, p.261). Because of its vastness and rural location, Alaska stands as
a forerunner in telemedical use for behavioral health (Nelson et al., 2012, p.10). Currently, pilot
and training programs for mental health telemedicine in Alaska are managed by Alaska Rural
Behavioral Health Training Academy (ARBHTA). This program trains professional utilization
techniques for telemedical equipment and decreases barriers associated with rural telemedical
care in Alaska (Nelson et al., 2012, p.14). Telemedicine has also transitioned into psychiatry.
AtlantiCare Regional Medical Center located in New Jersey initiated one of the first pilot
programs for tele-psychiatry (Clark et al., 2010, p.265). This program utilizes real time visual
and audio teleconference effects in clinical settings, with nurse monitoring of patient vital signs.
The model adopted by AtlantiCare Regional hospital serves as a solution for potential specialty
provider shortages in many locations (Clark et al., 2010, p. 265). Rural Alaska locations
including: Gateway Mental Health and State of corrections have also started small programs to
facilitate provider shortages. Programs like this offer distinct and needed psychiatry level care
for communities with no access (Patricoski, 2004, p.381). Barriers for telemedicine and
behavioral health include: cultural attunement, apprehension of technology, reimbursement rates
and technology adaptations (Nelson et al., 2012, p.14). In Alaska, ARBBHT commits much of
its time focusing on increasing cultural attunement or “cultural humility” for Native Americans
TELEMEDICINE & INPATIENT/AMBULATORY CARE 9
(Nelson et al., 2012, p. 11). Secondly, ARBBHT focuses on training participants and health
professionals for utilization of telemedical practices. Clinical supervision trainings happen
regularly, developing health care professional telemedical skills for program efficiency (Nelson
et al., 2012, p.11). Alaska Telehealth Advisory Council (ATAC) developed in 2009, also seeks to
limit barriers associated with telemedicine. ATAC helps with developing tele-psychiatry
standards for the state, resolving reimbursement issues and limiting technological limitations
(Patricoski, 2004, p. 372). Resolving barriers will ensure success for tele-behavioral/tele-
psychiatry health programs in both Alaska and other locations.
Inpatient care/Critical Access
Technology use within inpatient care facilities continues to grow. New ideas continue to
raise consumer expectations; leading greater demand for the best care a facility can offer (Shi &
Singh, 2013, p.106). Telemedicine leads technology benefits by allowing patients and provider’s
ways of communicating needed information and facilitating virtual visits between specialty
physicians and clientele (Shi & Singh, 2013, p.109). Two rural inpatient care networks are
assessed: chronic medical conditions and stroke/neurology.
Chronic medical conditions. In an overall study of mortality and disability causes in the
US, chronic medical conditions (CMC) rank number one (Rajan et al., 2013, p.127). CMC is
defined as a long term illness or condition with no current cure. Examples of CMC include:
Alzheimer’s, heart disease, obesity, Parkinson’s, chronic obstructive pulmonary disorder and
cancer (CDC, 2015, para. 1). Treating CMC can be challenging in rural locations. It is estimated
that 50% of individuals in the US have at least one CMC (Ward et al., 2014, p.1 ). With needs
unmet nationwide, rural locations suffer lack of coordinated care surrounding accessibility
(Rajan et al., 2013, p.128). Telemedicine provides rural locations accessibility to specialized
TELEMEDICINE & INPATIENT/AMBULATORY CARE 10
CMC provider care. Similar to other telemedical based programs, CMC utilizes video based
electronic communication to link physicians and patients over distances (Rajan et al., 2013, p.
128). Utilizing telemedicine for CMC patients increases stability by limiting time spent in
healthcare settings and by increasing independence from the burdens associated with CMC. Pilot
programs are currently being developed to improve CMC service and for continued research in
viable locations. Mercy Home Health system (MHHS) in Philadelphia, Pennsylvania recently
initiated a CMC pilot project allowing patients with a CMC treatment from remote locations,
instead of continually visiting their physician (Clark et al., 2010, p. 264). This program serves
several conditions including: congestive heart failure, chronic obstructive pulmonary disorder,
hypertension and diabetes. Telemedicine enables those with CMC freedom from periodically
visiting the hospital for care (Clark et al., 2010, p.264). There are also pilot programs more
specifically linked to specific CMC. SK Yee Medical Foundation in Hong Kong conducted one
of the first pilot programs that are currently researching the details telemedicine with
Alzheimer’s disease. Evidence from data revealed in this program revealed that telemedicine is
an effective way to treat and diagnose Alzheimer’s disease. Increasing services like SK Yee in
Hong Kong would improve accessibility of Alzheimer’s treatment in locations lacking specialty
care (Poon et. al., 2005, p.286). Programs like SK Yee Medical Center of Hong Kong, would
allow rural locations access to Alzheimer care needed. There are however, deficiencies
associated with the use of telemedicine for CMC services. MHHS’s home health project has
difficulties associated with technology for administering telemedicine within the outlying
locations. Pilot program evaluation reveals there are issues regarding monetary funding and
internet connection/video technology capabilities (Clark et al., 2010, p. 264). Care for those with
Alzheimer’s disease by telemedicine suffers from lack of research and limited pilot programs.
TELEMEDICINE & INPATIENT/AMBULATORY CARE 11
Pilot programs like SK Yee Medical Center in Hong Kong are few, especially if searching within
the US (Poon et. al., 2005, p. 286).
Tele-stroke/Tele-neurology. One of the more popular uses for e-health inpatient care is
tele-stroke. Cerebrovascular disease or stroke is considered the fifth leading cause of death in the
US (Mozzafarian et. al., 2015, p.229). Stroke is defined as a clot in your brain limiting cells to
their destination, eventually causing irreversible tissue death. Cases of stroke can end with
hospital treatment and physical limitations (Crespi et al., 2013, p.1083). Stroke patients require
efficiency and time sensitive care. National recommendations for patients suffering from acute
stroke conditions concur that receiving specialty care within three hours of symptoms limits
negative impacts from the disease process (Clark et al., 2010, p. 266). Rural locations struggle
with access to neurological providers extending time sensitive aid for those patients having
stroke complications. Barriers include location, lack of medical professionals, and cost of
specialty care (Clark et al., 2010, p.266). Rural locations benefit from telemedical neurologist
access. It also offers a cost-effective treatment for patients seeking care near home without the
requirement of travel. Telemedicine can offer primary care physicians a stroke network to offer
help and guidance in times of need. AntlantiCare of New Jersey piloted a neurology tele-stroke
program offering remote services to extended locations needing guided care (Clark et al., 2010,
p. 266). This program allows physicians the ability to access instrumental care from specialists
and save stroke related tissue death in their patients. This program offers full-spectrum care for
individuals who need pre-stroke consultation and after-stroke care (Clark et al., 2010, p. 266).
Another pilot program developed by Phillips health care has developed tele-stroke capabilities
for pre-hospital admission Emergency Medical Services (EMS) Personal. The objectives of tele-
stoke capabilities for EMS is to catch a potential stroke early, limiting tissue death and negative
TELEMEDICINE & INPATIENT/AMBULATORY CARE 12
side-effects (Bergrath et. al., 2012, p.1). This program offers physician guidelines via wireless
video technology for EMS personnel treating those with stroke symptoms. Program evaluation
revealed pre-hospital teleconsultation for stroke is feasible (Bergrath et. al., 2012, p.1).
Deficiencies associated with tele-stoke pilot programs are limited. The Atlanitcare tele-stroke
project included technology based limitations in their post analysis, detailing issues regarding
rural internet capabilities. Phillips health care also evaluated technology as the lead barrier for
routine use in pre-hospital tele-stoke equipment. Technological growth and improving broadband
capabilities of the future will ensure development of tele-stoke programs are a broader level
(Bergrath et. al., 2012, p.8).
Conclusions and Future Study
Telemedical studies provide research for possible productivity and advancements in
health care delivery. According to Choudhury et al., (2008) telemedicine is an effective way to
deliver health care services to remote regions (p. 1). Alaska is classified as officially having a
health service shortage, promoting the reason why telemedicine programs are vital (Choudhury
et al., 2008, p. 1). Each pilot program addressed above lists both strengths and weaknesses to
consider in development of future programs in both rural and urban locations. Predominant
evaluation measures are summarized below: (1) Telemedicine develops primary care by allowing
needed patient exams in a more economic and accessible manner (Shah, et al., 2013, p.229).
With telemedicine, primary care can increase patient quality of life by improving: timely health
care checkups, social functioning and treatment capabilities (Shah, et al., 2013, p.229). (2) It is
estimated that rural locations are underserved in mental health services by 60% (Roberts, et al.,
2011, p.10). Telemedicine expands behavioral health by providing needed screenings,
assessments, treatment and after care for those with inaccessible mental health issues (Nelson et
TELEMEDICINE & INPATIENT/AMBULATORY CARE 13
al., 2012, p.10). (3)Treatment of Chronic Medical Conditions (CMC) is a continued burden for
rural health care. According to Rajan et al., (2013), over 140 million individuals have at least one
chronic condition, and by 2030 it is estimated that 50% of Americans will have at least one
(p.127). Telemedicine improves treatment of CMC by increasing patient stability and
independence from current conditions (Rajan et al., 2013, p. 128). (4) Neurological complication
management is also improved by telemedical operations. E-health offers stroke patients fast
time-sensitive care for those in rural locations (Mozzafarian et al., 2015, p.229).
In conclusion, limited amounts of telemedial studies provide research for possible
productivity advancements in health care delivery. Ehealth provides an effective and promising
outlook for health care but deficiencies linger regarding evidential lack and inconsistency within
studies and performance evaluations (Ekeland et al., 2010 p.740).Currently, limited amounts of
pilot programs offer narrowly focused research, leaving uncertainty for major corporations and
lenders that desire to improve rural health care development (Ekeland et al., 2010, p. 739).
Developing rural health telemedicine projects should answer questions of concern regarding
development in: gender specific complications, service configuration and patient
satisfaction/experience (Ekeland et al., 2010, p.742). While there are limitations and deficiencies
associated with limited pilot programs, telemedicine does offer a persuasive outlook for the
future. According to Eron (2013), telemedicine is the future for health care, making it an
essential component of a healthy nation initiative (p.224).Telemedicine has transitioned into a
nationwide health improvement goal regarding information of dexterity and physician
involvement (Ekeland et al., 2010, p. 739). With growing involvement and positive pilot
program initiatives, e-health has the opportunity to improve rural health care on a broad level,
unseen today (Choudhury et al., 2008, p. 1). According to Williams (2008), the future of
TELEMEDICINE & INPATIENT/AMBULATORY CARE 14
telemedicine will be exciting, challenging and important for worldwide health care improvement
and (p.39).
TELEMEDICINE & INPATIENT/AMBULATORY CARE 15
References
Bergrath, S., Reich, A., Rossaint, R., Rortgen, D., Gerber, J., Fischermann, H., & Skorning, M.
(2012). Feasibility of Prehospital Teleconsultation in Acute Stroke - A Pilot Study in
Clinical Routine. Plos One, 7(5): 1-10. doi: doi:10.1371/journal.pone.0036796
Budetti, P. (2008). Market Justice and US Health Care. JAMA: The Journal of the American
Medical Association, 299 (1):92-94. doi: 10.1001/jama.2007.27.
Centers for Disease Control and Prevention (2015), Chronic Disease Prevention and Health
Promotion. Retrieved February 25, 2015, from
http:// http://www.cdc.gov/chronicdisease/overview/index.htm
Choudhury, A. H., Fisher, D. G., Pearce, F. W., & Fenaughty, A. M. (2008). A baseline study of
the factors that should be used to measure the effectiveness of Telemedicine. Academy of
Health Care Management Journal, 4(1), 1-16.
Clark, P. A., Capuzzi, K., & Harrison, J. (2010). Telemedicine: Medical, legal and ethical
perspectives. American Journal of Case Reports, 16(12), RA261-RA272.
Crespi, V., Braga, M., Beretta, S., Carolei, A., Bignamini, A., & Sacco, S. (2013). A practical
definition of minor stroke. Neurological Sciences, 34(7), 1083-1086.
doi:10.1007/s10072-012-1205-8
Ekeland, A., Bowes, A., & Flottorp, S. (2010). Effectiveness of Telemedicine: A Systematic
Review of Reviews. International Journal of Medical Informatics, 736-771.
doi: 10.1016/j.ijmedinf.2010.08.006.
Eron, L. (2010). Telemedicine: the future of outpatient therapy?. Clinical Infectious
Diseases, 51(Supplement 2), S224-S230. doi: 10.1086/653524
TELEMEDICINE & INPATIENT/AMBULATORY CARE 16
Mohatt, D. F., Adams, S. J., Bradley, M.M., & Morris, C. D. (2005). Mental health and
rural America 1994-2005: An overview and annotated bibliography.
Retrieved February 28, 2015,
from www.hrsa.govruralhealth/RuralMentalHealth.pdf
Mozzafarian, D., & Benjamin, E. (2015). Heart disease and stroke statistics. AHA
Statistical Update, 1(1), 295-295. Retrieved February 24, 2015, from
http://circ.ahajournals.org
Nelson, D., Hewell, V., Roberts, L., Kersey, E., & Avey, J. (2012). Telebehavioral health
delivery of clinical supervision trainings in rural Alaska: An emerging best practices
model for rural practitioners. Journal of Rural Mental Health, 36(2), 10-15.
doi:10.1037/h0095810
Patricoski, C. (2004). Alaska telemedicine: Growth through collaboration. International
Journal of Circumpolar Health, 63(4), 365-386.
Poon, P., Hui, E., Dai, D., Kwok, T., & Woo, J. (2005). Cognitive intervention for community-
dwelling older persons with memory problems: telemedicine versus face to face
treatment. International Journal of Geriatric Psychiatry, 20(3), 285-286. doi:
10.1002/gps.1282
Rajan, B., Seidmann, A., & Dorsey, E. R. (2013). The Competitive Business Impact of Using
Telemedicine for the Treatment of Patients with Chronic Conditions. Journal of
Management Information Systems, 30(2), 127-158. doi: 10.2753/MIS0742-1222300205
TELEMEDICINE & INPATIENT/AMBULATORY CARE 17
Shah, M. N., Gillespie, S. M., Wood, N., Wasserman, E. B., Nelson, D. L., Dozier, A., &
McConnochie, K. M. (2013). High‐Intensity Telemedicine‐Enhanced Acute Care
for Older Adults: An Innovative Healthcare Delivery Model. Journal of the
American Geriatrics Society, 61(11), 223-231.
Sorocco, K. H., Bratkovich, K. L., Wingo, R., Qureshi, S. M., & Mason, P. J. (2013).
Integrating care coordination home telehealth and home based primary care in
rural Oklahoma: A pilot study. Psychological Services, 10(3), 350-352.
doi:10.1037/a0032785
Shi, L., & Singh, D. (2013). Essentials of the U.S. health care system (3rd ed.). Burlington, MA:
Jones & Bartlett Learning.
U.S. Department of Health and Human Services: Substance Abuse and Mental Health Services
Administration Center for Substance Abuse Treatment (2009). Considerations for the
Provision of E-therapy. Retrieved (February 25, 2015) from
store.samhsa.gov/shin/content/SMA09-4450/SMA09-4450.pdf
Vanselow, N., Donaldson, M., & Yordy, K. (1995). A new definition of Primary Care. JAMA,
192(273), 1-3. doi:10.1001/jama.1995.03520270026023.
Ward, B., Schiller, J., & Goodman, R. (2014). Multiple Chronic Conditions Among US Adults:
A 2012 Update. Preventing Chronic Disease Public Health Research Practice and
Policy., 11(1), 1-4. Retrieved March 8, 2015, from
http://www.cdc.gov/pcd/issues/2014/13_0389.htm
White, H. L., & Glazier, R. H. (2011). Do hospitalist physicians improve the quality of inpatient
care delivery? A systematic review of process, efficiency and outcome measures. BMC
Medicine, 9(1), 58-79. doi:10.1186/1741-7015-9-58
TELEMEDICINE & INPATIENT/AMBULATORY CARE 18
Williams, S. (2008). Introduction to health services (7th ed.). Clifton Park, NY: Thomson
Delmar Learning.
top related