valley telehealth partnership: telemedicine readiness for the san joaquin valley

7/31/2019 Valley Telehealth Partnership: Telemedicine Readiness for the San Joaquin Valley

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Valley TelehealthPartnership

Telemedicine ReadinessEvaluation for theSan Joaquin Valley

Partners:Sponsor:


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Prepared for:

California Emerging Technology Fund

Prepared by:

Maria G. Pallavicini

Professor and Dean, School of Natural Sciences

Jennifer Smith

Telemedicine Project Manager

University of California, Merced

5200 North Lake Road

P.O. Box 2039

Merced, CA 95344Phone: (209) 756-7698

Fax: (209) 723-6450

http://naturalsciences.ucmerced.edu

Produced By:

Amy Moat

Director of Research and Communications

Great Valley Center

201 Needham Street

Modesto, CA 95354

Phone: (209) 522-5103

Fax: (209) 522-5116

www.greatvalley.org


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he San Joaquin Valley region of California is undergoing rapid transformation with a population growth that

is 65% higher than the states average and changing demographics. By 2020, the segment of population

above 65 years old, as well as the segment below the age of 24 two groups that generally consume more health

services than the rest of the population are expected to double in size. The rapid growth is accompanied by a

payor mix with a high fraction of Medicare and Medi-Cal reimbursements. Health care is further constrained by lack

of access to physicians and other health care professionals. The number of physicians and other health care

professionals per capita in the region is 30-50 percent lower than California as a whole.

The San Joaquin Valley, extending from Stockton to Bakerseld, includes a mixture of urban and rural underserved

regions. Rural areas are particularly challenged in providing health services, such as the ability to attract health

care professionals, lower rates of available core health care services, as well as access to specialty services in the

local area. These challenges lead to increased travel times to and from clinics, the need of patients to miss time

from work, which in turn increases the total cost of health care for the patient. Clearly, new models are needed to

help address the health care challenges in the region.

In 2007, UC Merced received an award from the California Emerging Technologies Foundation (CETF) to investigate

the San Joaquin Valleys telemedicine needs and readiness levels in support of developing a vision for a San

Joaquin Valley eHealth Regional Network. It is anticipated that this vision would help guide expansion and imple-

mentation of telemedicine in the San Joaquin Valley.

This report describes the analyses used to identify and characterize the

current needs and challenges of telemedicine in the San Joaquin Valley,

suggests how some of the challenges in telemedicine readiness could be

met over time, and identies - by a ranking system for telemedicine

readiness - participating health care sites most associated with the

likelihood of developing a sustainable telemedicine program. In

conjunction with support from other funding sources (AT&T Foundation

and Governors Partnership for the San Joaquin Valley), one product of

the analysis is the implementation of the Valley Telehealth Partnership

(VTP), a community-based networking resource for San Joaquin Valleytelemedicine users.

UC Merceds analytical approach involved multiple San Joaquin Valley

wide surveys of hospitals and healthcare clinics interested in using

telemedicine. Data collection was designed to understand the needs,

readiness levels, and physical/networking capabilities for installing

telemedicine in the reportedly interested facilities.

T

Executive Summary


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Data were organized into ten key indicator categories: 1) the organizations interest; 2) funding available; 3) patient

volume; 4) patient payor mix for reimbursements; 5) external referral rate to specialists; 6) lack of access to special-

ists; 7) the range of specialty needs; 8) physical space availability; 9) variety of use of telemedicine equipment; and

10) the organizations familiarity and capacity for new technology. A matrix of scores was derived for each site.

Sites with high scores across the ten indicator categories are likely to be facilities who are able to implement new

telemedicine programs most eectively at this particular point in time.

Overall, the data indicate that health care facilities are enthusiastic about using telemedicine to decrease the

disparities in access to patient care. Ninety-four percent of the Valley facilities are interested in using telemedicine,

and 72 percent of those reported being reasonably ready to do so.

The majority of survey respondents reported an absence of access for their patients who need specialty care. The

ten most commonly reported urgent needs for specialy medicine include: 1) cardiology, 2) dermatology, 3) psychiatry,

4) pediatric specialties, 5) gastroenterology, 6) orthopedics, 7) neurology, 8) psychology, 9) radiology, and 10) obesity.

Despite current economic challenges, most Valley facilities are increasingly comfortable using technology; the

majority of respondents to our survey access the internet through their facility regularly, and half are already usingT1 lines. Many of the rural sites are not far behind in the use of technology, illustrating that technology barriers

may not be as prominent as originally anticipated. Barriers to implementation of telemedicine in the San Joaquin

Valley are not necessarily the resistance of physicians, other health care professionals, or other administrative

bodies to invest in and use new technologies, but rather severe economic constraints in providing health care

access to segments of the population served in rural, underserved hospitals and clinics. Telemedicine equipment

alone will not x these challenges, such as making referrals to outside specialists, any less challenging.

Recommendations include:

Keeping a focus on profitability and sustainability;

Learning more about the key barriers for adoption of telemedicine by specialists;

Implementing a network and program design that delivers high quality service at reasonably low

monthly costs, with budget considerations for monthly line charges, equipment costs and maintenance,

program stang;

Offering training opportunities, networking opportunities and program development assistance to sites

to develop sta capacity;

Seeking out specialty providers who are interested in participating with telemedicine programs.

The viability of telemedicine as a solution in the region will depend on the providers and facilities abilities to

minimize costs, expand aordable access to specialists for low income patients, and dedicate time and resources

to program training, development and management. Identication of strategies to address each of the indicators

will be critical for telemedicine in the San Joaquin Valley and in regions where access is limited. Patients in rural

and underserved regions will be among those who benet most by telemedicine, yet they are often located in the

regions that pose the most challenging sets of circumstances for the creation of sustainable eHealth networks.


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Executive Summary

Project AreaProject Background

Telemedicine Background

The UC Merced Telemedicine Project

Methods

Data Collection

Data Analysis

Scoring and Weighting of Indicators

Results

Discussion of Key Findings

Recommendations & Summary

Conclusion

Endnotes

Appendix

Appendix A: Valley Telehealth Partnership Questionnaires

Site Assessment Questionnaire

Site Readiness Questionnaire

Appendix B: Summary of Questionnaire Results

Site Assessment Questionnaire


San Joaquin Valley Ranking Results

Appendix C: Questionnaire Score Cards for Ranking

Site Assessment

Room Accommodations

Network Accommodations

Table of Contents


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Table 1: San Joaquin Valley Facts 4

Figure 1: Percentage of Children (Age 0-17) living in Poverty in San Joaquin 6

Valley Counties

Table 2. Key Objectives of the Valley Telehealth Partnership Site Assessment 10

Questionnaire

Table 3: Indicators of Telemedicine Success 13

Table 4: Link between Survey Questions and Indicators 14

Figures 2a and 2b: Maps of Facilities Who Received and Responded to Questionnaires 15

Figure 3: Level of Anticipated Monthly Financial Commitment 16

Figure 4: Type of Facilities Who Responded to Questionnaire 17

Figure 5: Average Daily Number of Patient Visits (% of Facilities per County) 17

Figures 6a and 6b: Monthly Out-of-Town Referrals Reported (Average by County) 18

Figure 7: Patient Follow-through Rates with Out-of-Town Referrals for Selected Counties 19

Table 5: Top 10 Specialty Medicine Needs Reported in San Joaquin Valley 19

Figure 8: Current Use of Potential Telemedicine Room 20

Figure 9: Interest in Live Access to Interactive Continuing Medical Education for 21

Physicians and Sta

Figure 10: Current Type of Internet Connection 21

Table 6: San Joaquin Valleys Top Ranked Sites for Telemedicine Implementation 22

Table 7: San Joaquin Valleys Top Ranked Sites for Telemedicine Implementation 22

Before Disqualication Method

Table 8: Summary of the Chosen Sites for Telemedicine Implementation 23

Table 9: Common Reasons for the Failure of a Telemedicine System 23

List of Tables and Figures


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Eight Counties

27,280 square miles; 17% of the land area of California

3.87 million people;

>10% of Californias total population (2006)

1,543,700 employed people (2006)

up to 15.5% unemployed (2008)2

$24,244 per capita income (county average, 2005)

Table 1: San Joaquin Valley Facts1

The California population is growing faster than the

rest of the nation, and the Valleys population is

growing at a faster rate than the state average.

Through the year 2030, the growth rate of theregion is projected to be 65% higher than the state

average.3 The rapid increase is accompanied by

changing demographics. The segments of popula-

tion that are 65 years or older, or below the age of

24 two groups that generally consume more

health services than the rest of the population are

expected to double by 2020, an increase that is more than twice that projected for the nation. These data

indicate that health care needs of the Valley must be understood and addressed to ensure that access keeps

pace with population growth and that existing disparities are not exacerbated.

Access to health care in the San Joaquin Valley is considerably less than in the state as a whole. For example, 13.2%

of San Joaquin Valley people, ages 0-64, had no health insurance for the previous past year, compared to 11.5% of

Californians.4 In 2007, access to healthcare in the San Joaquin Valley was 27- 65% lower, based on the number of

primary care physicians and surgeons serving the residents in Fresno and Merced counties respectively, than the

The San Joaquin Valley comprised of the eight counties of Kern, Tulare, Kings, Fresno, Madera, Merced,

Stanislaus and San Joaquin, with sixty-two cities and more than 3.4 million residents has a long history of

contributions to the success of California, especially agriculture. The San Joaquin Valley, from Stockton to

Bakerseld, is well known as an agricultural powerhouse, with $23 billion in agricultural value earned

annually in the eight-county region.

Project Area


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All eight counties in the

San Joaquin Valley have

both geographic and

population shortage

areas for primary care

physicians, dentists, and

mental health professional

state average.5 The Federal Governments Health Resources and

Services Administration has designated Health Professional Shortage

Areas (HPSAs) in regions throughout the San Joaquin Valley. HPSAs

are census tracts with shortages of primary medical care, dental or

mental health providers and may be geographic (a county or service

area), demographic (low income population), or institutional

(comprehensive health center, federally qualied health center or

other public facility). All eight counties in the San Joaquin Valley have

both geographic and population shortage areas for primary care

physicians; six out of eight counties have a geographic or population

shortage area designation for dentists; and all eight counties have a

geographic shortage area designation for mental health professionals.

Once a largely rural area, the eight counties of the Valley, linked

by Highway 99, are now home to large metropolitan areas

(Stockton, Fresno and Bakerseld), as well as cities and towns

that contribute to its rural and urban diversity. Population

growth is driven primarily by migration. Almost 60 percent of

the San Joaquin Valleys growth since 2000 has been due to

migration, with the remainder attributable to natural increase

(the excess of births over deaths). In the north Valley, migration

accounts for almost two-thirds of the growth; a majority (70%)of migrants are from other parts of the United States and

California, mostly the Bay Area, and the remainder are interna-

tional migrants. In the south Valley, many of the international

migrants are from Mexico, are young, and tend to have larger

families than residents from other demographic groups. Natural

population increase accounts for almost half of the growth, and

international migration is about equal in size to domestic

migration.

The percentage of children under 18 years old who lived below

the poverty level in 2007 in the San Joaquin Valley was 28.6%,

compared to 20.8% of children in California.6


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0%

5%

10%

15%

20%

25%

30%

35%

Tula

re

Stanisl

aus

SanJo

aquin

Merce

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Mad

era

King

sKe

rn

Fresno

Figure 1

PERCENTAGE OF CHILDREN (AGE 0-17)

LIVING IN POVERTY, 2006

Source: U.S. Census Bureau

http://factnder.census.gov

29 2930

32

28

1920

28

California 18

Children living in poverty typically are unin-

sured or underinsured and therefore may

have limited access to heath care. Almost

42% of the children in the San Joaquin Valley

living below the federal poverty level are

currently uninsured.7 Poverty is associated

with increased risk of exposure to environ-

mental hazards and toxins and increased risks

to health due to lack of clean water, adequate

sanitation, nutrition, and shelter.8 Children

who do not speak English as a rst language

and who do not have access to linguistically

and culturally competent health care provid-

ers are at a severe disadvantage in accessinghealth care.9


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The beneits of

telehealth technologies

to the health-care system

far outweigh the costs of

implementation.29

Telemedicine networks are being used increasingly to address issues

of distance and health care access. The value of a successful

telemedicine program includes reduction of travel time and work

hours lost to traveling to a traditional out of town clinic, as well as

increased access to specialists and medical experts.14 Some

telehealth providers report that more than 85% of their patients

seen via telehealth remain within their community health care

environment, resulting in a reduction in unnecessary transfers, less

hospital lost revenueand the potential of enhanced economic

viability of the community hospital.15 Alaska, one of the largest

states territorially, but one of the least inhabited, has one of the

biggest telemedicine networks in the world,16 and has been

described as an encouraging example of a state that has success-

fully moved towards integrating a wide telemedicine network

among dierent health-care organizations.17 The Alaskan system is

a combination of federally funded initiatives in conjunction with

private medical organizations and institutions creating their own

telemedicine networks to reach remote areas. For example, the

Alaska Federal Health Care Access Network, which is designed to

serve federal beneciaries in the state, also serves approximately 50

percent of the states population.18

In Oroville, a town in Californias Sacramento Valley, approximately

90 miles north of Davis and its surrounding communities, desig-

nated as a health professional shortage area,19 98 percent of the

Telemedicine Background

Health care access is an essential component of human health. In the San Joaquin Valley, the shortage of physicians,

the geographic distances between cities and communities and a high number of under-served and poor

residents are barriers to specialty health care access.10 There are a number of rural areas in the United States and

the world that face similar challenges as the San Joaquin Valley for health care access. These challenges include

the ability to attract health care professionals,11 lower rates of available core health care services,12 as well as

access to specialty services13 in the local area, which leads to increased travel times to and from clinics, and time

missed from the workplace, which in turn increases the total cost of health care for the patient. Telemedicine has

been used to cope with some of these deciencies in some areas.

Project Background


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UC Merced is committed to improving the quality of life and health of the residents in theSan Joaquin Valley. UC

Merced is facilitating the establishment of a vibrant eHealth Network in the San Joaquin Valley, working with

three partners, the California Partnership for the San Joaquin Valley, California Emerging Technologies Fund(CETF), and the AT&T Foundation.

San Joaquin Valley Partnership In September 2007, UC Merced was awarded a Partnership Seed Grant to

begin implementation of 4 eHealth Centers in the Central Valley. The intended use of Partnership grant funding

was to establish four eHealth Centers throughout the San Joaquin Valley, with a hub located at UC Merced.

These four sites were envisioned to jump-start the development of a more comprehensive Regional eHealth

Network.

California Emerging Technologies Foundation (CETF) In October 2007, CETF awarded UC Merced a

grant to investigate the telemedicine needs and readiness levels of San Joaquin Valley to facilitate development

of a vision for a San Joaquin Valley eHealth Regional Network that could be used to guide telemedicine expan-

sion in the Valley. Data about the needs, desires, challenges, and feasibility of implementing a regional network

for telemedicine are critical to plana comprehensive Regional eHealth Network and for long term success of

telemedicine in the Valley.

parents/guardians stated that they wished to continue to

receive their consultations using telemedicine rather than

having to travel to the UCDCH [University of California Davis

Childrens Hospital] subspecialty clinic for routine face-to-face

appointments.20 Telemedicine has been used successfully for

treating hepatitis C patients in rural California,21

and in a numberof other areas including dermatology,22 psychiatry,23

cardiology,24 home health care,25 radiology,26 and other pediatric

specialties.27 The Center for Information Technology Leadership

(CITL)28 predicted savings of $4.3 billion per year if hybrid

telehealth systems were to be implemented in emergency

rooms, prisons, nursing home facilities and physician oces

across the US, and concluded that overall the benets of

telehealth technologies to the health-care system far outweigh

the costs of implementation.29 Overall, telemedicine networks

can increase productivity,30 which enhances the value of the

money already being invested in the health care system.

UC Merced


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AT&T Foundation In October 2007, UC Merced was awarded a grant from the AT&T Foundation to support

the implementation of telemedicine and eHealth Centers to address the San Joaquin Valley healthcare needs.

This funding is currently being used to support program development at each of the individual sites, and is

also providing much needed support to grow the Valley Telehealth Partnership (VTP), a UC Merced initiative

to develop a community-based networking resource for Valley telemedicine users

Statewide Telemedicine Initiative Towards the end of 2007, the University of California system was

awarded a $22.1 million dollar grant from the FCC to create the California Telehealth Network (CTN). The

statewide coordination of this project is being managed by the University of California, Oce of the President

(UCOP). The CTN project will fund the development and implementation of a statewide telemedicine network

that will connect approximately 500 individual facilities, including some sites in the San Joaquin Valley, for the

purpose of improving healthcare access. The CTN project oers opportunities for the San Joaquin Valley to

leverage resources for connectivity in a planned and phased process. The CTN will install telemedicine access

statewide, including across to the San Joaquin Valley. The visioning process will help position the San Joaquin

Valley to be integrated with and to leverage these exciting new opportunities.

This Report

The nal product of the CETF funded vision project is the analysis of telemedicine readiness levels and

technical capabilities of the San Joaquin Valley. It ranks 54 participating survey sites across ten key indicators

anticipated to indirectly predict future success in telemedicine use. The ranking provides foundational infor-

mation that could be used to assist in prioritizing connectivity of sites, improve levels of readiness in key

areas, and develop needed specic programs throughout the San Joaquin Valley. UC Merced envisions that

the information contained in this CETF funded site report will provide a data-rich backdrop regarding the

current readiness levels of multiple facilities across the San Joaquin Valley.


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MethodsData Collection

The overall goal of the San Joaquin Valley healthcare facility site assess-

ments was to identify the micro and macro needs, desires and present

realities of telemedicine readiness. The project proceeded in three phases:

site assessment, connectivity and implementation. Planning and data

collection involved multiple partners, including those with expertise in a

number of dierent areas related to telemedicine, as well as potential

clients and users.

Advisors consulted in the technical and program planning for the telemedicine initiatives, included individuals

from UC Davis, UCSF-Fresno, the American Telemedicine Association, the Great Valley Center, the California Tele-medicine and eHealth Center (CTEC), Rural Health Telecomm, AT&T, Kaiser, Anthem Blue Cross, and several other

smaller organizations familiar with telemedicine use. These groups assisted in developing criteria for site analysis

and placement, conducting gaps analysis, evaluating service models, estimating associated costs, and determining

timelines for implementation. The design of the questionnaire incorporated input from UC Davis, as well as consid-

erations from the California Telehealth Network (CTN) questionnaire.

The process for site and connectivity assessment included data collection through two rounds of questionnaires.

The questionnaires were distributed under the auspices of UC Merced and the Valley Telehealth Partnership (VTP)

(http://vtp.ucmerced.edu/pub/vtp_docs/home.html). The rst questionnaire was designed to assess needs and

interest. The second questionnaire was launched a few months later to understand the technical and physical

space accommodations at each site. Data were collected to meet 5 key objectives (see Table 2).

In addition to the key objectives listed in Table 2, the

VTP questionnaire was also used to assess willingness

to forge a strong partnership with UC Merced as a

partnering site.

The rst questionnaire, for site assessment, was mailed

to 133 San Joaquin Valley clinics and hospitals from

Stockton to Bakerseld. Sites were selected based on

location in either rural and/or underserved areas of the

San Joaquin Valley. A few sites from Mariposa and

Calaveras counties were also included.

2. Determine facility needs for telemedicine, includingexpected utilization (volume and type) and specic

specialist provider needs

5. Identify variables important for development of a

connectivity and implementation plan.

3. Better understand the operating environment that

exists for SJV facilities

4. Determine facilitys current level ofreadiness to

apply/use telemedicine

Table 2: Key Objectives of the ValleyTelehealth Partnership (VTP) SurveyQuestionnaires

1. Determine facility interest in using telemedicine


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Indicators

INTEREST

Telemedicine should be integrated into the overall core

mission and vision of the healthcare facility. Interest, willingness,

and commitment from both the administrative and physician sta

are imperative to ensure success. An organizationally-specic

value attached to the use of telemedicine is important, even for

short term success. Therefore, interest indicates the commitment

of the organization to provide health services through technology.

Typically, medical directors or CEOs completed the questionnaire. Questionnaires were delivered by land mail and

e-mail. Follow-up phone calls and incentives ($10 gift card) were used to increase the rate of return of completed

questionnaires.

The second questionnaire on site readiness was designed to collect information about each facilitys ability to

house a telemedicine program. Specically, the survey covered two key technical areas: physical accommodations

and networking accommodations. Data on the size, accessibility, noise levels, privacy issues, dcor, lighting,

availability, etc. characteristics of the room identied by the provider for telemedicine were collected. Data were

collected on the facilitys current network conguration including availability of space for new

equipment/connections, outlets/additional wiring, etc. This survey was sent to all 84 sites who had responded to

the rst survey.

The telemedicine data are maintained in an Open Source development system called Community Servers

(www.communityservers.com). This system runs on computers running Linux operating systems with three main

elements: the Apache Web server, Mysql database system, and the PERL scripting language. Data may be entered

manually (from mailed-in surveys) or immediately populated into the database via the web-based questionnaire

tool. A blogging feature was added to allow updates to individual records when additional contacts or new

information for sites becomes available. These features facilitate access to data in a user-friendly and ecient

manner, while automatically alerting the project manager when an update to the database has occurred.

Data Analysis

Healthcare facilities were ranked using ten specic macro indicators associated with successful implementation

and sustainability of telemedicine programs. These indicators were derived from shared experiences of telemedi-

cine users/programs at UC Davis, UCSF, Kaiser, Anthem Blue Cross, and several smaller, independent facilities who

have either successfully or unsuccessfully attempted to implement telemedicine programs (Table 4).

1


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FUNDING Organizations must have access to and approval for,

internal funding to support sustainable telemedicine programs.

Previous research31 has shown that a telemedicine system will fail if there is no

exit strategy after research or grant funding expires. Program support must

show up as a line item expense for the organization choosing to begin a

program or at a minimum show a willingness and ability to plan to allocatereasonable amounts of internal funds to continue the program after grants

expire.

PATIENT VOLUME Previous research has shown that a telemedicine

system will fail if the service is not needs-driven. Since the San Joaquin

Criteria for

Telemedicine

Success: Organizational

Capacity

Medical Needs

Technical Capacity

Valley has a region-wide shortage in physicians, particularly specialists, patient volume was considered to be one

measure of the level of overall need. Successful facilities will have a well-established patient base to support a nan-

cially sustainable program.

PATIENT PAYOR MIX FOR REIMBURSEMENTS A diverse patient payor mix that includes privately insured

patients will help to ensure viability of telemedicine programs. Facilities who rely solely on reimbursement

rates for the majority of patients (i.e. Fee for Service Medi-Cal/Medicare/Uninsured billings) will struggle to make

telemedicine sustainable without substantial grant funding.

LACK OF ACCESS TO SPECIALISTS Telemedicine is a needs driven technology, so a strong need in this

case, in the form of a need for greater specialty medical access must exist in order for it to grow and succeed.

Perceived and/or real decit to quality patient care as a result of inadequate specialty physician access is important to

ensure that referrals will be directed into the telemedicine system once implemented.

EXTERNAL REFERRAL RATE Current referral rates are often good predictors of a clinics potential success

in creating sustainable telemedicine programs. A facility poised to increase access using telemedicine

should be making external referrals outside of their community in an

eort to accommodate their patients care needs. Greater volume helps to

buer the costs associated with stang and program maintenance in

telemedicine, so clinics with low out-of-town referral rates will likely have

more diculty operating long term, nancially sustainable programs.Specialist (or hub) sites need only to demonstrate that they have the

ability to service patients outside of their community in a cost eective

way via telemedicine.

RANGE OF SPECIALTY NEEDS Multiple medical specialty needs

(by referring sites) are predictive of facilities that are likely to

utilize telemedicine. These sites for telemedicine are likely to become

2

3

4

5

6

7


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sustainable over time, due to the holistic utilization that would grow within an organization. Diversity of referrals

provides added strength.

APPROPRIATE PHYSICAL SPACE Unmanaged technical problems can be barriers to utilization of

telemedicine. The environment must support proper use of technology and ecient work protocols, such

as limiting disruptions or disturbances. Facilities must have access to an adequately sized, under-utilized andconveniently located room that will properly house the telemedicine equipment and allow for quality patient

interactions via telemedicine. Several variables are used to assess this indicator including use of the room 50

percent or more of the time for telemedicine, accessibility for patients and physicians, internet and phone connec-

tivity, appropriate lighting for optimal teleconferencing sessions, acoustic quality, etc.

VARIETY OF EQUIPMENT USAGE Successful telemedicine programs tend to serve more than one purpose

in an organization and therefore have a better chance of sustainability. Multiple uses of the telemedicine

equipment help to justify the expense of starting and operating a program and provide additional benets to a

facility and its organization. Uses other than direct patient health care include interactive continuing medical

education, peer to peer conferencing, patient education programs and live case reviews. Multiple use of equipment

translates to greater benets for the facility overall, and helps telemedicine to become more readily accessible to

multiple sta members, ensuring greater long term viability within an organization due to higher perceived

benet/cost ratios.

TECHNOLOGICAL FAMILIARITY Current use and familiarity with internet based applications in day-to-day

workows (i.e., internet based healthcare applications such as email, PAX systems, or electronic medical

record programs) is helpful when introducing the use of new internet and video conference based technologies.Facilities already incorporating the use of the internet have a greater likelihood of immediate program implemen-

tation than those that lack this familiarity.

8

9

10

Criteria Indicator Code Weight

Organizations Interest Interest 15

Funding Available Funding 15

Patient Volume Volume 5

Organizational

Capacity

Patient Payor Mix for Reimbursements Reimbursements 8External Referral Rate Referrals 10

Lack of Access to Specialists Specialists 10Medical Needs

Range of Specialty Needs Range 7

Physical Space Availability Space 15

Variety of Equipment Usage Equipment 10Technical

CapacityTechnological Familiarity and Capacity Technology 5

Total 100%

Table 3: Indicators of Telemedicine Success


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Scores for each indicator were weighted and then summed to obtain a nal overall score for the facility (Table 3).

For example, if a facility received the 20 maximum points allowed in the Interest Indicator, then the 20 was

converted to a weighted score of 15. Furthermore, nine specic questions were identied as absolute prerequi-

sites for the selection criteria; therefore, if the facility answered in the negative to any one of those 9 questions,

they were classied as not currently ready due to a lack of having key components in place.

Scoring and Weighting of Indicators

For each individual question, a number of points were allocated to specic

answers (see Appendix C). For example, the survey question Is gaining

access to medical specialists a problem for your patients? was answered

either yes or no. During the scoring process, an answer of yes to thisquestion was allocated 5 points, while an answer of no was not allocated

any points (zero). The questions were then grouped together by indica-

tors and the points were totaled per indicator. Using this score card, the

maximum number of points that could be earned for each indicator

category was determined. For each indicator, the highest scoring facility

was assigned a score of 100, and scores for other facilities are calculated

relative to the top score.

Table 4: Link between Survey Questions and Indicators

Indicator Code Total Number

of Questions

(from 3 surveys)

Maximum

Total Points

Allowed

Maximum

Points

Earned

(specic to

this data set)

Number of

Disqualifying

Questions

(automatic zero

for that indicator)

Maximum

Weighted

Points

Interest 8 20 20 4 15

Funding 12 45 42.5 2 15

Volume 6 25 25 -- 5

Reimbursements 1 6 6 -- 8Referrals 1 5 5 -- 10

Access 7 25 21 -- 10

Specialty 1 7 7 -- 7

Space 26 133.5 3121.25 15

Equipment 2 10 10 10

Technology 10 32 32 -- 5

Total 74 308.5 289.75 9 100

--


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Figure 2b

DISTRIBUTION OF HEALTH

CARE FACILITIES THAT

RESPONDED TO BOTH

QUESTIONNAIRES (N=47)

Figure 2a

DISTRIBUTION OF HEALTH

CARE FACILITIES IDENTIFIED

AND RECEIVED FIRST

QUESTIONNAIRE (N=133)

ResultsThe response rate of health care facili-

ties to both surveys was approximately

63 percent. The site assessment ques-tionnaire was completed by 84 of 133

San Joaquin Valley clinics and hospitals

in the Stockton to Bakerseld region. Of

the original 84 respondents, 54 (64%)

responded to telemedicine readiness

survey. The distribution of responding

sites to each questionnaire is shown in

Figures 2a and 2b.

All sites were notied at the outset that

UC Merced intended to use the informa-

tion to assist in creating an eHealth

network for the San Joaquin Valley.

Furthermore, those sites that received the

second survey were also notied that the

University anticipated augmented fund-

ing for the purchase of additional

telemedicine equipment (Proposition 1D),

and that the survey would help the

University determine which San JoaquinValley participants could begin using

telemedicine most expediently. Even

with a steady ow of follow up calls and

emails over a six week collection period

and incentives (gift card) many of the

non-participating facilities did not return

calls or emails.


19/69

$2,600 and up2%

$1,300 - $2,50015%

$600 - $1,2004%

$200 - $50051%

None28%

Figure 3 LEVEL OF ANTICIPATED MONTHLY

FINANCIAL COMMITMENT

Multiple factors may have contributed to incomplete responses to the surveys. Some of the previous contacts

were known to have left their respective facilities. In 2008 many facilities became understaed, often with a loss

of the key sta person who had originally completed the rst survey. Some clinics had gone out of business

between the rst and second survey cycle. The lower than expected response rate to the second survey was

most likely due to the fact that this survey required more specic information requiring considerable time and

eort to collect and report. These factors, coupled with the fact that data were requested during a period of

severe state budgetary constraints, may have decreased the priority of completing the surveys. In addition,

many sites who initially showed interest in using telemedicine before the states budget crisis may have

simply felt too overwhelmed by budgetary issues to commit to starting anything new when the second survey

FINDING:

The majority of surveyed

health care facilities in

the San Joaquin Valley

are interested in

implementing

telemedicine.

arrived. Finally, it is possible that a handful of sites did not have any

viable space to realistically accommodate telemedicine, and therefore

chose not to complete the survey with outwardly negative answers.

Indicator Findings

Interest

Establishing a baseline of interest from San Joaquin Valley facilities to

use telemedicine is essential before suggesting it as a broad solution for

access to specialty care. Ninety-four percent of the sites were interested

in incorporating some form of telemedicine into their facilitys opera-

tions. Most sites (91%) indicated that they believe the majority of

physicians would be interested in using telemedicine, while only seven

percent (7%) were unsure and two percent (2%) uninterested.

FINDING:

Most facilities in the San

Joaquin Valley would be

interested in starting a

telemedicine program

now

if they could aordto do so.Funding

The level of nancial commitment that a facility is currently

providing or willing to provide to support functions such as

connectivity, videoconferencing, and sta training for telemedi-

cine was evaluated. More than 50 percent of respondents

reported a readiness to spend between $200 and $500 per

month on funding a telemedicine program. Approximately 22

percent reported being able to spend more, whereas nearly 30

percent reported that they were unable to fund any additional

costs. Only one rural behavioral health clinic site reported a

readiness to spend more than $2,500 a month. Most respon-

dents reported a willingness to dedicate some sta time to

training to ensure a successful program. Overall, 72 percent of

sites report being able to commit $200 or more per month to a

program, as well as a commitment from both administrative and

clinical sta.


20/69

Figure 4

TYPES OF FACILITIES WHO RESPONDED TO QUESTIONNA

Rural Behavioral Health Clinic 1%

UrbanOutpatientClinic26%

Rural Outpatient Clinic55%

Rural Hospital18%

0%

20%

40%

60%

80%

100%1,000

500-9

100-4

0-99

Calave

ras

Fresno

Kern

King

s

Mad

era

Marip

osa

Merced

SanJo

aquin

Stanisl

aus

Tula

re

Figure 5 AVERAGE DAILY NUMBER OF PATIENT VISITS

(PERCENTAGE OF FACILITIES PER COUNTY)

Volume

The general environment in which health care is

delivered is an important consideration in

developing strategies to increase access to

specialists via telemedicine. The majority of the

facilities surveyed described themselves as

outpatient clinics (80%). Although many of these

clinics reported signicant challenges in providing

mental health services to their patient base, only

one percent of the facilities responding to the

survey were specically dedicated to providing

behavioral health.

Reimbursements

Facility designation as a Rural Health Center

(RHC) or Federally Qualied Health Center

(FQHC) is important when considering reim-

bursement rates and the population served. As

reimbursement rates are typically higher for

facilities with these designations, RHC and FQHC

facilities have larger prot margins than those

without these designations. Approximately 65

percent of the sites were FQHC and 35 percent

were RHC.

The distribution of payment for medical services

is one consideration in developing a nancial

model for telemedicine. Medi-Cal payors make

up the largest percentage of the current patient

base in the San Joaquin Valley, accounting for

approximately 75 percent of payments received,

except for the sites from Calaveras and Mariposa

Counties those counties not ocially consid-

ered part of the San Joaquin Valley which

reported much lower Medi-Cal rates. Merced

County sites reported that approximately 69

percent of their patient payments come from the

Medi-Cal program.

FINDING:

Multiple clinics have sucient patient

volume to support a sustainable

telemedicine program.


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Tular

e

Stanisl

aus

SanJo

aquin

Merced

Mad

era

King

sKe

rn

Fresno

Figure 6a

MONTHLY OUT-OF-TOWN REFERRALS REPORTED

(AVERAGE BY COUNTY)

10.0

189.2

35.5

0

50

100

150

200

18.8

10.0

30.0

102.5

25.0

8.3

102.5

Marip

osa

Calav

eras

Figure 6b

MONTHLY OUT-OF-TOWN REFERRALS REPORTED,

PER 100,000 POPULATION

Source: State of California, Department of Finance, E-1 Population Estimatesfor Counties January 1, 2008. Sacramento, California, May 2008

Tula

re

Stanisl

aus

SanJo

aquin

Merced

Mad

era

King

sKe

rn

Fresno

Marip

osa

Cala

veras0

30

60

90

120

150

NumberofOut-of-TownReferralsper100,000Population

AverageNumb

erofOut-of-TownReferrals

The federally subsidized Medicare program accounts for an average of 18 percent of all patient payment types in

the San Joaquin Valley, and is the second most common payor type. Other types of payors include uninsured

patients and locally subsidized, government programs, such as Healthy Families (7%).

Overall, these data indicate that approximately 75 percent of all patient payments received by San Joaquin Valley

healthcare facilities derive from either state or federally subsidized healthcare plans and uninsured clientele.

Approximately 15 percent of patient payments received are cash (typically health insurance deductibles and

co-pays), and the remaining 10 percent are payments received through private insurance reimbursements.

Non-Local Referrals

The volume of out-of-town referrals reects limited access to local specialists at the health care facilities or in the

region. Health care facilities in Fresno, Merced, and Tulare counties reported the highest rates of out-of-town

referrals for medical specialists. Interestingly, the population size and density in each of these counties is substan-

tially dierent as is the patient volume at the responding clinics. The lack of specialists operating within thesecounties contributes to a signicant shortage of resources for delivery of medical care, both for low

income/uninsured patients as well as for paying patients. The population density demographics in these regions

suggest that rural status alone does not necessarily constitute the greatest need for improved access to specialists.


22/69

0%

20%

40%

60%

80%

100%76 - 100%

51 - 75%

26 - 50%

11 - 25%


23/69

Figure 8

CURRENT USE OF POTENTIAL TELEMEDICINE ROOM

Barrier to Utilization of Outpatient Telemedicine

May Present Some Problems for Telemedicine

Highly Satisfactory to Support Telemedicine

Emergency, Triage,

or Surgery Rooms

20%

Patient Consult

or Not in Use

56%

Adminstrative/Office,

Exam, or Proceedure

Rooms

24%

Physical Space

The proper physical environment to install and use the technol-

ogy in a patient care setting is critical for a sustainable telemedi-

cine program. Four (7%) sites reported having more than one

room that could be used for telemedicine. However, only 7 (13%)

expected that a specic room could be used full-time fortelemedicine. Promisingly, 85 percent of the rooms could be

used for telemedicine at least 50 percent of the time, which is

satisfactory for beginning a telemedicine program. Also, 98

percent of these potential telemedicine rooms are conveniently

located for physicians to use regularly throughout the day, within

a 5 minute walk or less.

A wide range of room settings were reported. More than half

(54%) the rooms have windows with window coverings. The

color on the walls, the condition of the paint, the type of ooring,

and the light sources in the room spanned a range of combina-

tions, but nearly all of the rooms would be satisfactory for

telemedicine use.

All the rooms had at least two electrical outlets.

About 65 percent of the rooms had a phone jack or

line that could be used for telemedicine purposes,such as incoming and outgoing calls; only 59 percent

responded that computer networking jacks were

already located in the room. For those currently

without phone lines, when asked if it were possible to

bring in another phone line, 58 percent (11)

responded negatively. Those same 11 facilities also

responded that there were no computer jacks. There-

fore, 20 percent (11 out of the 54 total rooms

reported) automatically do not meet the minimum

requirements for their specic room to be used for

telemedicine.

This data are helpful in determining the costs associ-

ated with room preparations (lighting, wall color,

sound panels, etc.) and connectivity accommodations

for each site.


24/69

Technology

The results of the technological readiness question-

naire demonstrate that most San Joaquin Valley

facilities surveyed are well prepared to begin using

internet based technologies, as they are already

connected to and using the internet (96%). There

were no reports of using dial-up connection, and

nearly half of those using the internet have imple-

mented T1 lines. The majority (96%) of sites also

reported having an IT sta or team that could assist

with troubleshooting technology problems and

maintain their current network and equipment -- an

outcome that greatly exceeded our original expecta-

tions. Even though a small number of survey ques-

tions had a high no response rate, such as the

preferred placement if a T1 line were brought in, this

may be due to the lack of specialized technological

knowledge of the individual completing the survey

rather than the actual technological capacity of the

entire facility sta. Furthermore, when asked if they

had any preference on brand names for new network-

ing equipment UPS, routers, and switches 91

percent were able to identify their preferences.

Variety of Equipment Usage

Approximately 90 percent of San Joaquin Valley sites reported that they are primarily interested in conducting outpatien

specialty consults with their patients. Most facilities (89%) saw value in interactive continuing medical education,

such as patient rounds, as a part of their sta training programs, with three-quarters (75%) reporting that sta woul

be interested in accessing these educational benets weekly or biweekly.

FINDINGS:

Most (89%) of the facilities are willing to

commit sta time to training required to

use telemedicine successfully.

Internet connectivity among sites

exceeds 95 ercent.

Figure 9INTEREST IN LIVE ACCESS

INTERACTIVE CONTINUIN

MEDICAL EDUCATION FO

PHYSICIANS AND STAFF

NotIntereste

d

11%

Interested

89%

Annually2%Quarterly

5%

Monthly

29%

Biweekly

24%

Weekly

26%

Unsure

14%

DSL/Cable13%

Satellite2%

HDSL 4 mbps

2%

Fiber

9%

DSL/Cable

13%

10 med DSE3

18%

T1 Line56%

Figure 10

CURRENT TYPE OF INTERNET CONNECTION


25/69

KEY FINDING:

Overall, the data regarding

facilities readiness shows

that the real barrier to

adopting telemedicine

successfully in the San

Joaquin Valley is economic.

In summary, data collected using the survey/questionnaire approach indicated that most San Joaquin Valley facilities

participating in the survey are comfortable using technology. Thus, technological barriers are not as high overall as

was originally anticipated. Several concerns about space issues, such as phone and computer lines, etc. could be

surmounted easily, with additional planning. If other key program factors are already in place, such as a strong

interest, need and nancial support, these details become less important in the overall set up of establishing a

telemedicine program.

Recommendations for Site Prioritization

The telemedicine readiness of sites that responded to both

questionnaires was assessed using a ranking system (see

methods section) based on analysis of the indicators

described in previous sections. Health Care Facilities with the

top ten ranks are shown in Table 6. Table 7 displays those sites

that would have ranked the highest if they did not lack a keycomponent, which ultimately disqualied their score.

The top 10 ranked sites list is a way to see all of the indicators

combined into one score. For instance, Clinic #16 is at the top

of the list for many reasons (see Table 8). The ranking data

suggest the facilities that are the most ready, committed, and

able to start a new telemedicine program at this particular

point in time (2008), per our indicators and weighted scoring

criteria.

Transitional

Rank(out of 54 sites)

Clinic

Code

#

Location

County

Transitional

Score(without

disqualiers)

Missing Key

Component(s)

1 3A Tulare 91.2 Space

2 26B Stanislaus 89.3 Space

3 43 Tulare 86.3 Funding

4 37 Kern 85.7 N/A

5 29 Kern 85.4 Space

6 16 Fresno 84.5 N/A



9 47 Tulare 82.6 Funding

10 26A Stanislaus 82.6 Space

Table 7: San Joaquin Valleys Top Ranked Sitesfor Telemedicine Implementation BeforeDisqualication Method

Table 6: San Joaquin ValleysTop Ranked Sites for TelemedicineImplementation

Rank(out of

54 sites)

Clinic

Code #Location

County

Final Total

Score(out of 100 points)

1 16 Fresno 70.0

2 37 Kern 68.0

3 36 Kern 65.6

4 12 Fresno 65.2

5 23 Kern 64.4

6 15 Fresno 62.6

7 14 Fresno 59.4

8 21 Kern 59.4

9 24 Kern 59.4

10 9 Kern 59.4


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DiscussionAlthough telemedicine has the potential to improve health care access and have economic benets for individual

and the community, there are a number of common challenges identied in establishment of a telemedicine

system (Table 9).

Addressing these challenges will be essential for success once health care facilities are equipped with telemedicine

equipment.

The data-driven approach to assess telemedicine readi-

ness informs about the needs and challenges faced by San

Joaquin Valley healthcare providers and facilities. The

overall facility response rate was approximately 65 percent

for each survey issued, which demonstrates that the

interest of San Joaquin Valley health care facilities in

telemedicine is signicant, but lower than expected

overall. Possible explanations for the disinterest of nearly

35 percent of those we tried to survey may suggest an

unwillingness or inability to use telemedicine at this time,

previous engagements with other groups to use telemedi-

cine, a lack of time or resources to complete the survey,

and/or confusion regarding the various telemedicine

surveys, as multiple inquiries and eorts have recently

circulated their way through the Valley (including groups

such as: the California Telehealth Network, California

Valley Health Network, Adventist Health Systems, UC

Davis Rural PRIME program, etc.) as a result of growing

telemedicine interest in the state.

Table 9: Common Reasons for theFailure of a Telemedicine System33

the service was not needs-driven

there was no commitment to provide the service

there was a lack oftraining

there was no suitable exit strategy after researchfunding expired

there was poor communication

there were technical problems

work practices were not updated

the protocols for use were poor or non-existent

Table 8: Summary of the Chosen Sitesfor Telemedicine Implementation

Interest ~ They currently have buy-in for telemedicine

from administration

Funding ~ They have the ability to partly nance

monthly costs ($200-$500)

Volume ~ Their patient volume averages 45 daily visits

Reimbursements ~ They average about 45% of theirreimbursements from private insurance, and about 25%

from Medi-Cal (signicantly higher and lower, respec-tively, than the average from the sample)

Referrals ~ They currently make about 65 out-of-townreferrals monthly

Access ~Their highest specialty needs are for cardiology,

nutrition, dermatology, allergy / immunology, andpsychology

Specialty ~ They have an interest in using telemedicinefor outpatient specialty consults

Space ~ They have appropriate space to house theproject, which includes a 10 x 10 room in good condition,big enough for networking equipment, which has

electrical outlets and DSL internet connection

Equipment ~ They are interested a wide range of using

the equipment, including telecardiology, CME, teleradi-ology, teleophthalmology, telepharmacy

Technology ~ They may have some upfront costs to setup the room, such as putting a phone line, computer

jacks and UPS in the networking room, but they havethe capacity to do so


27/69

Many San Joaquin Valley

facilities are open to

using technology.

The majority of survey respondents reported the absence of access for

their patients who need specialty care. Due to the overwhelming need to

improve access and patient follow-through rates, 94 percent of the

facilities responding to our questionnaire are interested in using

telemedicine, and 72 percent of those report being reasonably ready to

do so.

These data and subsequent analysis may be informative to suggest

prioritization for telemedicine implementation. It should be recognized,

however, that health care in the San Joaquin Valley is highly dynamic and

evolving and that data collected represent the state of readiness in 2008.

The ability of these data to project readiness for years in the future needs

to be assessed. For instance, recent developments in the Californias

deteriorating nancial situation have begun to negatively aect many

safety net facilities and could soon render some of the San Joaquin

Valleys higher ranking sites unable to aord telemedicine. Conversely,

sites scoring lower initially may have made operational changes to allow

for greater need or accommodation of a telemedicine program. Thus,

these data must be used cautiously and not over-interpreted in the

development of an eHealth network for the San Joaquin Valley. It is

recommended that each facility be contacted again, prior to implemen-

tation planning, in order to conrm their ability to support a program.

Despite existing economic challenges, most San Joaquin Valley

facilities are becoming more comfortable using technology; the

majority of respondents to our survey access the internet

through their facility regularly, and 50 percent are already using

T1 lines. Although it was not specically asked in the question-

naire, we learned that many sites are also in the process of

installing EMR and PAX systems (digital radiology). These data

indicate that many of the rural sites are not far behind in the use

of technology, and that technology barriers may not be as high

originally anticipated. It is important to note that the economic

situation is a real barrier in this region and not necessarily the

resistance of physicians, other health care professionals, or other

administrative bodies to invest in and use new technologies.


28/69

Over recent years, telemedicine has assisted many small, medically underserved communities in California to

narrow the gap to access between rural primary care providers, their patients, and the medical specialists practicing

in distant locations. However, our data for the San Joaquin Valley points out that the challenges of access to medical

specialists is not just distance, but high levels of poverty that threaten to minimize the eectiveness of telemedicine

solutions.

Currently, 75 percent of all patients seen at the facilities we surveyed reportedly use federal or state subsidized

healthcare programs to access care, or are uninsured. For the most part, specialists are unable or unwilling to accom-

modate these patients due to low reimbursement rates and labor intensive paperwork. The impact of these realities

on telemedicine for specialty care cannot be underestimated. While conducting on-site interviewswith administrators

at rural facilities after they had submitted their questionnaires, it was surprising to learn that telemedicine is not

necessarily new in the San Joaquin Valley. Several groups interested in our project had already tried to begin

telemedicine programs and failed. They shared with us that, although they were able to achieve the necessary

funding for connections and equipment, the lack of aordable specialists available to their patients for consultation

via telemedicine eventually sealed the fate of their program. Other strains on these programs included limited funds

for program operations, such as telemedicine coordinators, program promotion and training. As a result of these

discussions, the importance of planning for all aspects of telemedicine should not be underestimated.

The top challenge is

affordability.

In order for telemedicine to benet local communities, the realities of the

San Joaquin Valley payment environment must be taken into account and

integrated into the overall planning for telemedicine program design.

Since most of these facilities will be unable to aord the discounted fees

oered by academic facilities, such as the UC Medical Centers of Excellence,other arrangements will need to be made. Operational costs will also need

to be minimized in order to create sustainable programs that will benet

the San Joaquin Valley for the long-term. Additionally, because telemedi-

cine is typically not a protable venture for several years, it is important to

bear in mind that small organizations must demonstrate or receive the

means to support a program until this benchmark is achieved. Otherwise, it

is highly likely that these eorts will have similarly short lived life spans to

those which failed.

Due to its nancial complexities and severe problems with accessing

medical specialties, the San Joaquin Valley provides a challenging real-

world classroom for those who are interested in learning how to create

sustainable telemedicine solutions that serve low income populations.

Such solutions will call for great collaboration amongst healthcare and

community groups who are interested in providing and improving such

access, and overcoming current obstacles.


29/69

Reported Referral and Follow-through Rates:

Interestingly, there were county-specic dierences in the reported needs for specialists and estimated rates of

follow-through for specialty referrals. For instance, Merced County reported a high volume of need for specialty

referrals (102 per month), followed by a 25 percent or lower rate of follow-through for 80 percent of referred

patients. Similarly, Fresno Countys rural facilities reported a high referral volume (189 per month) with 54

percent of referred patients following through 50 percent or less of the time.

High referral rates for a facility in more populated area is reasonable, but it is surprising that the follow-through

rates in these same counties (such as Fresno and Stanislaus) are low to moderate as many of the specialists in

the San Joaquin Valley are located in surrounding cities such as Fresno and Modesto. Anecdotal information

suggests that transportation is the largest barrier. These data suggest that telemedicine consultations, even in

the more populated areas of the San Joaquin Valley, have the potential to greatly improve the rates of follow-

through for specialty consultations.

Physical and technical accommodations:Thirty-six percent of sites who responded to the rst telemedicine readiness survey chose not to participate in

the second survey that focused on physical and technical program capacity. This was surprising, but there may

be several reasons for the lack of participation of a subset of respondents. The second survey required more

detailed information about each sites physical and networking accommodations and therefore required more

sta time and high level responses from IT professionals. We

assume that several sites chose not to take the time to com-

plete this survey due to either a lack of time, people or expertise.

Some facilities may have chosen not to participate in the

physical/technical survey after realizing they did not have

space to utilize telemedicine. Finally, the nancial situation of

many of the facilities during the second survey process became

severely strained due to the state budget impasse in California.

This may have forced many groups who had shown interest in

using telemedicine in the rst survey to focus on other, more

pressing concerns.

For those who did respond to the second survey, a large majority

of sites (86%) reported being able to dedicate rooms that could

be to be used for telemedicine 50 percent or more of the time,

the ideal minimum time allocation for development of successful

programs. Ninety-eight percent of these rooms were also located

within a 5 minute walk for physicians. This is an important

component, as physician accessibility to telemedicine should fall

closely in line with current routines for successful adoption.


30/69

Most facilities are not familiar with the requirements involved in

generating high-quality outpatient telemedicine consultations, so

specic details were gathered about each of the facilitys potential

rooms and their locations in order to properly evaluate their appropri-

ateness for telemedicine and estimate cost levels for set up.

Out of 54 surveys, 22 percent of the rooms suggested for use for

telemedicine facilities were found to be inadequate or inappropriate

for outpatient telemedicine consults due to their current uses as

emergency rooms (20%) or administrative spaces (2%). Thirty-ve

percent of rooms were next to a busy area with lots of noise a detail

that does not support telemedicine activity due to the need for

high-quality sound over video conferencing equipment, as well as the

need for patient condentiality. Facilities suggesting the use of these

types of rooms for telemedicine would need to nd better suitedspaces or postpone their use of telemedicine until conditions were

improved, since the quality of the patient and physician experience is

paramount to its continued use and overall success.

Ninety-six percent of surveyed sites reported having an IT team in

house that could assist them with their telemedicine connection and

equipment. This is a strong indicator that the San Joaquin Valley

facilities responding to the second questionnaire are already investing

in the human aspect of their technology infrastructure, and are very

supportive of the needs associated with using telemedicine. Facilities that are already sustaining these expenses

will most likely be able to begin using telemedicine at lower costs, more quickly, and with greater long term

success.

Both room and network accommodation details in non-critical areas varied widely across the sites. Details such as

the wall paint, ooring and lighting, window coverings, the number of electrical, phone and networking outlets

and available copper wiring were elements that were taken into consideration in the scoring process. Sites

needing the least cosmetic or networking modications were ranked higher due to lower costs and work associated with set up. Many of these variables are simple and inexpensive enough to modify, so facilities who can aord to

do the work should not be overly concerned with these elements when selecting the best room for their program.

Conversely, sites on tight budgets may want to scrutinize these elements when making the decision to proceed.

Some modications such as equipment type, etc. can help to bridge the gap between sub-optimal spaces, but

other elements are non-negotiable (such as too much noise, inappropriate mixed use space and greater distance

from physicians) and must be evaluated before investments are made.

San Joaquin Valley

facilities are already

investing in thehuman aspectof

their technology

infrastructure.


31/69

Recommendations and SummaryTelemedicine Doesnt Fix the Economic Divide

Regardless of the real-time proximity that telemedicine can provide between patients and physicians located in

separate communities, the low-income environment in the San Joaquin Valley will continue to perpetuate a

divide between quality medical specialists and low-income patients. Though many referring sites are able to

demonstrate the need, interest and readiness required for successful use of telemedicine, other serious

challenges remain on the specialist side of the consult.

Telemedicine equipment alone will not x these challenges. Most specialists cannot aord to provide service to

patients with low reimbursement rates; the consequence is that specialists typically accept only a few uninsured

patients at a time, if at all. Furthermore, due to a shortage of specialists overall, most of these physicians are

already overbooked with protable, privately insured clientele, and therefore are un-likely to see telemedicine

as a positive addition to their practice.

Specialty Recruitment is Greatly Needed

Currently there are few specialists available to consult with San Joaquin Valley patients via telemedicine, either

due to aordability issues or lack of equipment on their end. Even if every site that scored well on the readiness

surveys became equipped tomorrow, access to care in the Valley would improve minimally since so few special-

ists are available.

These realities are important to consider when planning for the

expansion and use of telemedicine in the San Joaquin Valley, and

should not be overlooked. Since telemedicine does not work

without specialists on the other end of the call, these challenges

must be focused on and met creatively over time. Keeping this in

mind, realistic solutions should consider that:

1. Telemedicine is not for everyone. Not all physician specialists

are willing or able to use telemedicine or to serve low incomepopulations. Rather than try to convince non-interested groups

otherwise, eorts should instead be focused on those who are

interested. Physicians who are attracted to exible working condi-

tions, new technologies, the ability to work from home, or to screen

patients remotely in advance (to ensure higher-quality referrals)

should be prioritized when seeking out specialty providers.

Cultivating strong

relationships

with specialists

is critical to theoverall future of

telemedicine.


32/69

2. Healthcare is a business.Therefore, protability is important. All

planning for telemedicine should center around creating value that

can be measured by enhanced protability. For instance, a program

that helps surgical specialists remotely screen incoming referrals can

result in more surgery time and less un-protable, expensive (high

operational costs) oce consults. Post operational check ups could

be handled similarly, saving time and money. The business model on

the specialists side must be considered and looked at creatively

when determining whether or not telemedicine could be useful to

them in their day to day practice.

3. Relationships require understanding. Cultivating strong relation-

ships with specialists who are interested in using telemedicine and who can do so protably is critical to the

overall future of telemedicine, especially in the San Joaquin Valley. At this time, in order for this to occur in a large

enough scope, a greater understanding of the key barriers for adoption of telemedicine by specialists must bedeveloped so that eective solutions can begin. Without the appropriate understanding of these barriers,

attempts at solutions are unlikely to change outcomes for the better.

Controlling Costs and Investing in Training is Key

In order to ensure viable, long-term solutions for improving access at the San Joaquin Valleys referring sites,

several actions will need to be integrated into regional plans for expansion. Some suggestions to accomplish this

objective include:

1. Minimize the economic strain of telemedicine by ensuring the costs for operating individual programs areaordable for each facility. Implementation of network and program design that deliver high quality service at

reasonably low monthly costs, including budget conscious considerations for monthly line charges, equipment

costs and maintenance, program stang, etc. will be needed;

2. Oer training opportunities, networking opportunities and program development assistance to sites to

develop the human infrastructure necessary to sustain successful telemedicine programs will help to ensure

long-term success;

3. Identify medical specialists who are willing and able to see subsidized or uninsured patients via telemedicine while

providing them with training and equipment to do is critical to the viability of telemedicine in the San Joaquin Valley.

Sustainability

In order for telemedicine to succeed, both referring and consulting sites must look to create sustainable programs

that will grow and provide greater patient access and quality care without diminishing their organizations

protability. In order for this to occur, basic business planning should be conducted in advance of program

adoption to ensure that the investment in telemedicine is sensible and able to be sustained over time.


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ConclusionThe comprehensive site assessment study suggests that much of the San Joaquin Valley is ready to begin using

telemedicine to increase access to health care specialists, but there is still much work to do. The viability of

telemedicine as a solution (albeit partial) in the region will depend on the involved providers and facilities abilities

to minimize costs, expand aordable access to specialists for low income patients, and dedicate time and resources

to program training, development and management. Identication of strategies to address each of the variables

will be critical for telemedicine in the San Joaquin Valley and in regions where access is limited. Patients in rural and

underserved regions will be among those most beneted by telemedicine, yet they are often located in the regions

that pose the most challenging sets of circumstances for the creation of a sustainable eHealth networks.

In order to craft well designed solutions to these challenges, more information regarding the barriers to adoption

of telemedicine by medical specialists is needed. Unless enough specialists can be recruited, trained and equipped

to handle the referral volume/variety needed by telemedicine end users, telemedicine will continue to oer little

benet to patient care overall.


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Endnotes

1. California Department of Finance, California County Proles (2007)

2. State of California, Labor Market Information Division, (last viewed December 19, 2008)

3. California Department of Finance, California County Proles (2007)

4. California Health Interview Survey (2007), UCLA Center for Health Policy Research

5. RAND California Database, 2007, using HCFA Medicaid Statistics



8. Suk WA. 2002. Beyond the Bangkok Statement: research needs to address environmental threats

to children's health. Environ Health Perspect110:A284-A286

9. National Standards for Culturally and Linguistically Appropriate Services in Health Care. Report for U.S. Department of Health

and Human Services, Oce of Minority Health. 2001.

10. For general information regarding rural health issues, see Committee on the Future of Rural Health Care: Institute of Medicine.Quality Through Collaboration, The Future of Rural Health. Washington, DC: National Academies Press, 2004.

11. See, Hart LG, Salsberg E, Phillips DM, Lishner DM. Rural health care providers in the United States. J Rural Health 2002; 18 (suppl.)

211-32; and Williams JM, Ehrlich PF, Prescott JE. Emergency medical care in rural America. Ann Emerg Med2001; 38: 323-7.

12. Blumenthal D. New steam from an old cauldron: the physician supply debate. N Engl J Med2004; 350:1780-7.13. Rheuban, K S. The role of telemedicine in fostering health-care innovations. J Telemed Telecare 2006; S2:46

14. See, e.g., Hailey D, Roine R, Ohinmaa A. Systematic Review of evidence for the benets of telemedicine. J Telemed Telecare. 2002

8 (Suppl. 1):1-30; and Hailey D, Ohinmaa A, Roine R. Study Quality and evidence of benet in recent assessments of telemedicineJ Telemed Telecare 2004;10:318-324.

15. Rheuban, at 46, citing: Carlson, RP. Can telemedicine deliver what it promises? Fam Pract Manage 1996;3:36-45.

16. Ohinmaa, A. What lessons can be learned?. J Telemed Telecare 2006; S2:43

17. Ohinmaa, ibid.

18. Regan Foster, Telemedicine reaches over 200 Alaska locations,Alaska Journal of Commerce, January 27, 2003 available at:

http://www.alaskajournal.com/stories/012703/foc_20030127016.shtml (last viewed on January 14, 2009); see also, HHS Secretary

Leavitt Travels to Alaska to Advance Rural Health Initiatives, News Release, US Department of Health and Human Services,

July 22, 2008, available at: http://www.hhs.gov/news/press/2008pres/07/20080722b.html (last viewed on January 14, 2009).

19. HPSA Designation Criteria, HRSA Website, available at: http://bhpr.hrsa.gov/shortage/hpsacrit.htm (last viewed January 14, 2009)20. Marcin, et al., Using Telemedicine to Provide Pediatric Subspecialty Care to Children With Special Health Care Needs in an

Underserved Rural Community. Pediatrics 2004;113;4, available at: http://www.pediatrics.org/cgi/content/full/113/1/1

(last viewed on January 14, 2008).

21. Lorenzo Rossaro, M.D., Christopher Aoki, M.D., Jihey Yuk, B.S., et al. The Evaluation of Patients with Hepatitis C Living in Rural

California via Telemedicine. Brief Communication, Telemedicine and e-Health, Vol 14 No. 10, 1127-1129.

22. Mort M, May CR, Williams T. Remote Doctors and Absent Patients: Acting at a Distance in Telemedicine? Science, Technology, &

Human Values. 2003;28:2;278; Whited JD. Teledermatology. Current status and future directions. Am J Clin Dermatol. 2001;2;59-64

23. Callahan EJ, Hilty DM, Nesbitt TS. Patient satisfaction with telemedicine consultation in primary care: comparison of ratings of

medical and mental health applications. Telemed J. 1998;4:363-369.

24. Sable CA, Cummings SD, Pearson GC, et al. Impact of telemedicine on the practice of pediatric cardiology in community hospitaPediatrics. 2002;109(1), available at: http://www.pediatrics.org/cgi/content/full/109/1/e3 (last viewed on January 14, 2009).

25. Jerant AF, Azari R, Nesbit TS. Reducing the cost of frequent hospital admissions for congestive heart failure: a randomized trialof a home telecare intervention. Med Care. 2001;39;1234-1245.

26. Franken EA, Jr, Berbaum KS. Subspecialty radiology consultation by interactive telemedicine. J Telemed Telecare. 1996;2:35-41.

27. Karp WB, Grigsby RK, McSwiggan-Hardin M, et al. Use of telemedicine for children with special health care needs. Pediatrics.105:843-8

28. Cusack CM, Pan E, Hook JM, et al. The Value of Provider-to Provider Telehealth Technologies. Center for Information Technology

Leadership. Chicago, IL; Healthcare Information and Management Society, 2007, available at:

http://citl.org/_pdf/CITL_Telehealth_Report.pdf (last viewed on January 14, 2008).

29. Cusack CM, Pan E, Hook JM, et al. The value proposition in the widespread use of telehealth. J Telemed Telecare. 2008; 14:167-168

30. Ohinmaa A, What lessons can be learned? J Telemed Telecare 2006; S2:43

31-34. Brebner, JA, Brebner EM and Ruddick-Bracken H. Experience-based guidelines for the implementation of telemedicine serviceJ Telemed Telecare. 2005;11 (Suppl.1): S1:3-4.


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APPENDIX A:Valley Telehealth Partnership

QuestionnairesSite Assessment Questionnaire



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UC Merceds Valley Telehealth Partnership Questionnaire

The purpose of this questionnaire is to assess your facilitys level of interest in becoming atelemedicine partner with UC Merced in its Valley Telehealth Partnership program. Pleaseanswer all of the following questions to the best of your ability and forward the completed surveyto Jennifer Smith at: UC Merced, Attn: Jennifer Smith, Natural Sciences Dept. P.O. Box 2039

Merced, CA 95344. Thank you for your participation!

Name: __________________________________Title: ______________________________

Organization Name: __________________________________________________________

Physical Address of Facility/Clinic: ______________________________________________

City: _________________________ County: ______________________Zip: ____________

Phone: _____________________________ Alternate Phone: _________________________

Email: ______________________________Website: _______________________________

Are you a Key Decision Maker at this facility? Yes No

Is your location considered rural or urban? Rural Urban

Are you a recognized FQHC facility? Yes No

Please circle the best description/s of your facility below:

Hospital (in/out patient services) Outpatient Clinic Behavioral Health Clinic

Please circle the best description of your provider type below:

Community Health Clinic Mental Health Clinic Rural Health Clinic

Non-Profit Hospital For-Profit Hospital Other: ______________

Are you interested in using telemedicine at your facility? Yes NoIf no, why not? _________________________________________________________

If yes, which uses are you most interested in? (Circle all that apply)

Outpatient Specialty Consults Distance Continuing Ed Inpatient Specialty Consults

E/R Consults Tele-radiology Tele-pharmacy

Tele-cardiology (store/forward) Tele-ophthalmology Tele-Ultrasound

Tele-fetal monitoring Patient Monitoring (real time) Other: _____________________


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What is your clinic/facilitys daily visit average? ___________________________________

What is your clinic/facilitys annual visit average? _________________________________

How many PCPs practice in your facility? _____________________________________

How many PAs practice in your facility? ______________________________________

What is the estimated payor mix of your current patient base?

(Please estimate by percentage for each category)

______% Cash _______% Medi-Cal ______ % Other:__________________

______% Private Insurance _______% Medicare

Which five specialty referrals are most commonly needed by patients seen in your fac

valley telehealth partnership: telemedicine readiness for the san joaquin valley

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