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Report

"Minority Health Professions Schools Telemedicine Assessment Report"

January 1997

On behalf of
National Library of Medicine
By Neal Neuberger
Health Tech Strategies
&
John Scott
Center for Public Service Communications

 


"Minority Health Professions Schools Telemedicine Assessment Report"

I Preface

The twelve member institutions of the Minority Health Professions Foundation include medical, dental, pharmacy, and veterinary medicine schools at mostly historically black American colleges and universities. According to the mission statement in its publication A Catalyst for Change, the Minority Health Professions Foundation was founded to improve the health status and quality of life of medically underserved Black and other racial and ethnic minority groups. As a catalyst, the Foundation promotes optimum health among poor and minority people by "engaging the collaborative resources of minority health professions schools." Historically, this collaboration has been facilitated by personal communication, postal correspondence, travel and physical presence. This has been largely effective, as evidenced by the achievements of the member-institutions of the foundation, but not efficient in terms of expenditure of financial and human resources.

Each of the Foundation's members has its own distinct and historic mandate for providing education, research, and health care services, and each has its own internal information collection, and management schemes and external alliances that have been developed to plan for and respond to institutional missions. Although the overall objectives of many of the organizations are similar, and each of the Foundation's members has committed to work together, it is also the case that certain categories of information are proprietary to the member-organization and, therefore, not available, except under some specific circumstances, for public access. This being said, there is a wealth of information that could be shared between and among Foundation members and other appropriate parties if a mechanism were developed to make sharing possible without requiring significant human or financial resources and without putting unreasonable demands on any organization to change the methods of operation to which it has become accustomed.

Respecting this, the scope of the proposed MHPF initiative calls for creating a network that would make best use of the combined assets of all member-institutions while at the same time enhance the ability of each individual institution to pursue its own mission.

The degree to which this initiative proves effective will be, in large part, the degree to which the Foundation is successful at engaging all relevant parties at the earliest possible time so that they are full collaborating partners to the process. It is hoped that Foundation members will agree to devote time and resources to a constructive discussion leading to creation of a system capable of sharing information because they perceive the resulting system will add value to their current operations.

 

II. Introduction and Project Overview

The Minority Health Professions Foundation (MHPF) has been working collaboratively with the Center for Public Service Communications (CPSC) in Arlington, Va. to develop and strengthen telecommunications linkages among MHPF member institutions. Such links will be invaluable as information sharing tools for a number of potential applications in clinical care, distance education, medical research, and administration. An extension of these links into underserved urban and rural communities of the United States will directly enhance the foundation's ability to fulfill its mission to improve the health status of minorities and disadvantaged persons.

Overall the efforts of the "Telehealth" network will support the goals of the foundation to:

A. Improve the health status of minority and disadvantaged persons;
B. Expand Improve the health status of minority and disadvantaged persons;
C. Expand the number of minority health professionals in medicine, dentistry, pharmacy, and veterinary medicine and to expand service to underserved populations;
D. Enable disadvantaged students to become health professionals;
E. Conduct Research on health problems of special importance to minority populations and on health service utilization and delivery of services for minorities and other underserved populations
F. Expand the number of minorities in faculty and other leadership positions in health professions schools;
G. Provide health services to minority and underserved populations in coordination with the education and research missions of the association; and
H. Strengthen and enhance the capabilities of the minority schools so that they are better able to fulfill their educational and other missions.

Leveraging a planning grant of National Library of Medicine, CPSC/MHPF propose to work on an ongoing basis with other government organizations, academia, and the private sector to establish a sustained telecommunications effort in pursuit of these vital public health oriented goals.

 

III. Planning Grant Implementation

Phase 1 Telecommunications Survey

To begin, CPSC staff conducted site visits at the twelve core project institutions at nine locations:

A. Charles R. Drew University of Medicine and Science Los Angeles, CA
B. Florida A&M University College of Pharmacy and Pharmaceutical Sciences Tallahassee, FL
C. Hampton University Hampton, VA
D. Howard University Colleges of Medicine, Dentistry and Pharmacy Washington, DC
E. Meharry Medical College Nashville, TN
F. Morehouse School of Medicine Atlanta, GA
G. Texas Southern University College of Pharmacy and Health Sciences Houston, TX
H. Tuskegee University School of Veterinary Medicine Tuskegee, AL
I. Xavier University of Louisiana College of Pharmacy New Orleans, LA

Phase 2 Planning Conference

In a second phase, a two-day planning conference was held on February 27-28 at the National Library of Medicine in Bethesda, Maryland consisting of IRM directors, lead clinicians, administrative staff and appropriate guests and speakers (including key state and federal agency and private sector representatives) to review the draft implementation plan, receive comment and then redraft the plan as working document towards full "Telehealth" system execution. Options for individual school participation in existing or emerging telemedicine-related networks will also be explored as part of the agenda.

Among the issues discussed at the planning conference:

A. potential applications of telecommunications and information technologies between and among the schools;
B. priority content areas to be addressed;
C. identification of potential technologies that are appropriate from a user perspective;
D. affordability and availability within the constraints of prospective funding
E. a discussion of potential funding and implementation options

IV Changing Trends for Consideration with Respect to a "Telehealth System" for the Minority Health Professions Schools

Some of the significant trends which are going to continue to effect the development and dissemination of telemedicine in the private sector are thought to include:

A. Medical Education -- Changing Role of Academic Health Care

Many of the early (and in fact ongoing) research, demonstration and evaluation efforts with regard to telemedicine have been based at or operated in conjunction with medical schools or academic health centers (AHCs) throughout the U.S. Examples include programs or projects at University of Arizona; University of Arkansas; University of Colorado; Dartmouth; East Carolina University; Medical College of Georgia; Indiana University; University of Kansas; LSU New Orleans; University of Michigan; University of Nebraska; State University of New York; Oregon Health Sciences Center University; University of Pennsylvania; University of Virginia; University of Washington; West Virginia University and others.

Just as there has been a high degree of interest on the part of major academic health centers with regard to telemedicine, the role of AHCs in a reformed health care environment remains uncertain. As health care reforms proceed in the marketplace, and government continues to ratchet down payments under Medicare and Medicaid (including set asides for graduate medical education and residency slots), the use of telecommunications on an ongoing basis poses an interesting question. Telecommunications infrastructure is expensive and much of the work that has gone on till date has been funded through grants from the federal government. Now that these programs are facing severe budget constraints will academic health centers be able to continue their commitments to the telemedicine development work they've begun? On the other hand will they see advantage in continued telemedicine investment as a means of obtaining referrals from outlying areas, in the process expanding market share in competition with local managed care organizations ?

In part the question hinges on the willingness of major medical centers to shift their technology focus from pure or basic scientific or health services research to the economics of the situation they face. Depending on the answer, telecommunications for the delivery of care will either be of burden or benefit to their mission.

B. The Move Towards Managed Care

Hospital systems and managed care organizations are just now beginning to realize the promise of telecommunications in health care, both as a means of extending lower cost health services to an expanded population base, and as a way of capturing new market share. The move towards managed care anticipates a whole new set of players and providers as well as the information tools to assist them. It is widely accepted that "business as usual" health care delivery in the United States is no longer acceptable, radical changes underway are evidence of the insistence of major employers, insurers and the patients they cover. This is especially true for many of the specialized (and traditionally expensive) medical services including radiology, pathology, psychiatry, urgent care and others. Often these services are not uniformly available in underserved rural and urban areas of the United States at any price, necessitating costly patient or clinician transfer to achieve coverage. To the extent that telemedicine can help increase access and reduce costs while preserving quality, the three major goals of system-wide health care reform may at least in part be addressed by using these new management and service delivery tools .

While major systems and managed care organizations have been slow to adopt new telecommunications technologies in pursuit of these goals, there is ample evidence that lead organizations are beginning to pay attention. The American College of Radiology, American Hospital Association, American Medical Association, American Osteopathic Healthcare Association, Federated State Boards of Medical Licensure, Health Information and Management Systems Society, and Voluntary Hospitals of America, Inc. have all undertaken some type of organized activity aimed at identifying issues and opportunities in the field.

Just as leading telecommunications companies are beginning to align themselves strategically with rivals in a new telecommunications era, so too are most major health care concerns in an ongoing fight to preserve market share within a declining revenue base. Organizations are increasing their responsibility for the provision of vertically-integrated services, increasing their capacity to provide a continuum of care which ranges from preventative to acute to long term services. Massive industry restructuring including consolidations and mergers like

Columbia/HCA, and the recent SunHealth and AmHS/Premier merger which created the nation's largest health care network, will likely usher in telemedicine programs of unprecedented scope and scale.

 

C. Shared Decision Making

At the same time, many major health care organizations are beginning to adopt a more "patient centered" approach which heavily emphasizes principles of empowerment and shared decision making among care givers and their clients. The Hanover, New Hampshire-based Foundation for Informed Medical Decision Making, headed by Dr. John E. Wennberg of Dartmouth, gathers and disseminates accurate and understandable information about the nature and potential outcomes of alternative treatments -- so that patients and physicians, working together, can share in making informed medical decisions. Computer-based programs are designed and produced for use in the healthcare provider setting which allows patients to move through the programs of most interest, providing information about their conditions along with unbiased descriptions of the potential benefits of alternative surgical and non-surgical interventions. A videotape program of interviews with patients of similar experiences has also been established so that consumers may use them at home in further answer to their questions.

In time, organized systems of care throughout the nation will have to become more accountable to patients and purchasers, and information technologies will play an integral role in the planning and execution of these patient centered programs.

D. Increased Emphasis on Population-based Health

Yet another trend with regard to telecommunications in health care, is high level interest in population -based or "public" health. The extent to which population based health programs meet their goals depend in large part on the effective collection, analysis, use and communication of health-related information. In April of 1995, the Public Health Service sponsored a first ever conference at the National Library of Medicine focusing on barriers and opportunities to the use of National Information Infrastructure Technologies for the information problems of population-based public health. Among other issues the conference identified the following major barriers to effective implementation:

! A lack of nationally uniform policies to protect privacy while permitting critical analytic uses of health data;

! A lack of nationally uniform, multipurpose data standards that meet the needs of the diverse groups who record and use health information

! Insufficient awareness of the applicability of NII technologies in meeting the information needs of population-based public health

! A public workforce that lacks essential information technology skills; and

! Organizational and financing issues that make it difficult to integrate information systems or bring potential partners together

The report also outlines by way of illustration various ways in which NII technology could be used to improve the health of the public.

A follow-on strategy session including CPSC principals proposed a strategic plan focusing on a wide-range of actors to help overcome these barriers.

E. Alternative Sites for Care Delivery

There is clearly a major shift under way in the financing and organization of health care delivery in the United States. Part of the changing environment includes health care reformers who are questioning many of the traditional care giving settings from a cost and appropriateness point of view. The use of physician extenders, and new diagnostic and therapeutic interventions is making it easier to provide care in alternative care sites including ambulatory care settings, nursing homes, patient's homes, and smaller easily accessible clinics in outlying areas.

A series of recent articles in Telemedicine Today for instance (Spring 1995, September, and December 1995) focuses on home health applications of telecommunications. According to the lead article "Telemedicine would seem to be an ideal way of supplying the observational and cognitive skills of a nurse, while eliminating the "wind-shield time" that eats up so much of a visiting nurse's day". This is not an small issue in consideration of statistics by the National Association of Home Care which estimated nearly half a billion home health visits in 1993.

Tele-home health projects are underway through a number of vendors and sites. American Telecare, Inc., in Minnesota; md/tv Inc., in Florida; Tevital, Inc of Pennsylvania and H.E.L.P. Innovations, in Kansas have been active in the field.

American Telemedicine Association President Jay Sanders, M.D. has suggested that in time, modifications to existing cable infrastructures or the use of ISDN will allow interactive medical care to be delivered in a patient's home via something akin to what he calls a "home medical channel". Various scopes and peripherals will allow many diagnostic and monitoring modalities and applications.

Already, on-line service providers, dial-up servers and direct Internet access services are beginning to provide an array of interactively available information to patient's homes. A PC-based system at the University of Wisconsin called Comprehensive Health Enhancement Support System (CHESS) offers a range of personnel health information, support services and problem solving tools including modules concerning breast cancer, AIDS, sexual assault, alcoholism and stress management. The Harvard Community Health Plan provides around the clock access via an interactive database to guide Burlington HMO members through questions about their condition, and then advises them of the need for further medical attention. Other at-home on-line services include American Online's "Better Health and Medical Forum" and CompuServe's "Health and Fitness Forum".

In addition to at-home health services , other non-clinical settings are being actively tested for telehealth services. The University of Texas Medical Branch at Galveston and at the East Carolina University Correctional Telemedicine program offer an alternative to costly and disruptive transfer of prisoners for health care service.

Even mobile tele-medical services are being contemplated. Mobile magnetic resonance imaging (MRI), children's preventative health vans, and other services are being considered as potential remote sites to tertiary care centers who may give instant specialty consultation while diagnostic or preventative health care vans are still out in the field.

F. The Increasing Role of States

The changing role of government is apparent at all levels and stands to significantly effect the emerging relationship between health care and telecommunications. The current federal policy debate with regard to the Medicaid program, and resurgent attempts to block grant other health and social welfare programs is illustrative of the national trend towards an renewed role for state government in the delivery of services. Already responsible for implementation of many telecommunications-related regulations and programs, states stand to take on newly expanded roles for the delivery of many government-financed health services. Already many states have made substantial resource and policy commitments to the field of telemedicine. Several organizations including the CPSC, Intergovernmental Health Policy Project (IHHP) of George Washington University, and the Telemedicine Information Exchange at Oregon Health Sciences Center have tracked the development and implementation of telemedicine activities on the part of individual states including Georgia, Iowa, Kansas, Louisiana, North and South Carolina, New Mexico, Oklahoma and Texas. Both CPSC and TIE remain ongoing sources of current information with regard to telemedicine activities.

While some states have enacted restrictive or enabling licensure or other regulatory provisions, others have been actively involve in the planning and execution of public-private partnerships which have set up state-wide telemedicine and related networks. Using an informal case study approach, the IHHP recently issue a two volume report identifying the many different activities among 30 states which they surveyed.

In addition, the National Governors Association and Western Governors Association (WGA) have each expressed considerable interest in the issue. At its 1994 winter meeting, the Western Governors established a Telemedicine Policy review Group consisting of senior state officials, telemedicine experts, and other interested parties to help the governors address individually and collectively the major barriers to the more widespread use of telemedicine. An WGA Telemedicine Action Report was issued which sets forth recommendations in the areas of infrastructure planning and development, telecommunications regulation, reimbursement for telemedicine services, licensure and credentialing of telemedicine providers, medical malpractice liability, and confidentiality of electronic patient records.

Finally, a National Forum on Telemedicine and Health Informatics: Issues for Consideration at a State and Local Level was held by the Center for Public Service Communications in coordination with Utah Governor Mike Leavitt and the Utah Department of Health this past September in Park City, Utah. With participation of the federal Office of Rural Health Policy, Association of State and Territorial Health Officials and National Association of City and County Health Officials, forum proceedings including recommendations will be included in an upcoming edition of Telemedicine Journal.

G. Human Factors

One of the major issues facing the field of telemedicine is the degree to which health care providers and administrators will adopt new telecommunications technologies into their everyday practice. Federal program staff are well aware that many of the grant projects they administer are significantly underutilized relative to the technology investment which have been made.

While CPSC and others have worked to identify a whole range of issues, obstacles and opportunities facing the field, none appear to be more critical to the successful incorporation of telecommunications in health care than the "human dimension" issues. Various policy development efforts have culminated in the delineation of the many regulatory, standards, legal and policy issues confronting the field, yet few have looked at the more subtle and serious questions of leadership, organization, individual and institutional comfort level, training, and related matters. One such study was conducted by CPSC last January for the federal Office of Rural Health Policy, is available in draft form and entitled "The Human Dimension of Telemedicine: Report of the ORHP Workshop on Barriers to Practitioner Acceptance".

Clinical acceptance is an major matter for public and private sector health care organizations, and is currently a topic for consideration by the Institute of Medicine in its evaluation of telemedicine. Resolution of these issues will likely occur in the form of awareness of the benefits to be gained; user-friendly technology design and implementation; better needs assessments; identification of lead change agents in institutions; societal readiness; better teaching and training towards a more technology literate professional staff; and a better understanding of overall changes taking place in the health care system and in the individual delivery environment. A process of "human factors re-engineering" has been called by some who have closely studied the situation.

 

V. General Findings and Observations

Site visits were conducted starting August 6, 1996 to assess the current status and needs of each member institution in order to determine the requirements for telemedicine and medical informatics applications across a range of current teaching, training, research and clinical programs. In preparation for visits with key administrators, lead clinicians and technical staff, CPSC distributed the following research questions to help guide in-person interviews.

CPSC Research Questions for the
"Telehealth System for The Minority Health Professions" Project

Programs/Applications

1. Please describe your institution's telemedicine and medical informatics programs. Examples might include:

-- Videoconferencing for teaching, clinical care, or health services administration;

-- Training of medical informatics specialists;

-- Use of personal computers by students to remotely access medical literature and information (such as National Library of Medicine's Medline)

Please also describe the objectives of these programs as they relate to your institution's mission.

2. Please briefly describe teaching, training, clinical and research relationships where telecommunications and information technologies are used to facilitate linkages with:

-- Other academic institutions (inside and outside of AMHPS)

-- Health care organizations;

-- Government agencies (i.e., Veterans Health Administration, Department of Defense, Department of Health and Human Services); or

-- Community groups

3. If you share telecommunications and information technology resources with other departments within your institution, please describe your

departmental relationships with respect to access to these technologies (i.e., procurement, management, payment, etc.)

Functionality/Outcomes

1. Have any formal evaluation efforts of your telemedicine projects been undertaken from a health services research perspective? What have been the findings?

2. Can you provide any anecdotal information regarding the success or failure of these telemedicine-related programs?

3. Please discuss what you have found to be the relative costs of using telecommunications as part of -- or as substitute for -- face-to-face teaching, clinical, or population-based public health programs?

Technology Utilized

1. Please provide a general description of technologies being used, including videoconferencing; desktop multi-media; mainframe computing; intra or Internet applications; voice or audiographic networking etc.

2. What telecommunications capabilities do you have i.e. T-1 connectivity, fiber optic, satellite links, ISDN etc.? Who pays for or provides these linkages?

Human Factors/Personnel

1. How are your telecommunications related projects/programs accepted by educators, students, and the patients they serve?

2. Do you believe that your faculty and students have an understanding/appreciation of how telecommunications technologies are being used in the teaching; delivery; research; and administration of health and veterinary services?

Through a combination of interviews during site visits, general observations, follow-on discussions, and phase two conference activities, the following summary of activities constitutes the major relevant resources within the Minority Health Professions member schools:

 

Charles Drew University of Medicine and Science

Visited August 6, 1996. Primary Contacts: Sac Caruthers / Dr. Charles Flowers, Dean

CPSC met with several Drew leadership and staff interested in pursuing applications of telecommunications primarily for neuro-ophthalmology, family medicine, and radiology.

There is a high degree of interest in linking as many as five private (and other presently public) clinics within a ten mile radius of Drew to facilitate the integration of inpatient and outpatient care. Pressures of managed care, the need to provide continuous on and off-site residency training, and increasing requirements to monitor quality have led several Drew staff to look at various mostly computer-based options for creating a seamless electronic medical record which includes charts, x-rays and other views, appointment scheduling and eventually billing. Drew itself uses a Novell operating system, pentium processors, 4-5 dedicated communications lines and a data server. Presently its referring clinics use a variety of systems. Drew has begun discussions with a Seattle-based group called M.D. Microsystems Inc. (also being used by Univ. of South Carolina, Univ. of Wisconsin, and Univ. of Texas Galveston) to provide cross over provider level support and systems integration. In anticipation of a system involving its clinics, Drew has begun to train its residents to directly input patient clinical and administrative data.

In addition to interoperability problems with nearby clinics, Drew lacks sufficient capacity to provide faculty and researchers with E-mail and internet connectivity. Faculty expressed interest in obtaining minimally acceptable Intranet/internet capabilities including hardware, software, dial-in access, and training in how to use the system.

At the same time, Drew is sensitive to the autonomy of county and other health care institutions with whom it relates. It therefore would like to see some pilot project which allows some common level of information exchange while preserving the opportunity of partner institutions to grow individually.

Drew envisions working more closely with the county and with private industry to create a system which helps local public sector health care organizations compete effectively in an managed care environment.

In an indication of community connectivity, Drew's radiology department has already begun a digital radiology project involving the Humphrey Clinic (5 miles away) which has a Kodak donated film digitizer and sends images to a viewing station in the hospital's ER for interpretation by residents after hours and on weekends. The goal of the project (which is also supported by a $400,000 CalRens connectivity grant) is to further connect CT and MR to the system. Discussions are underway with Pac Bell, Loral and Whitiker Clinic regarding the ongoing status of the project. Discussions have also taken place with the Department of the Navy with regard to a research effort aimed at comparing storage using a distributed archiving system.

Florida A&M University College of Pharmacy and Pharmaceutical Sciences

Visited October 1, 1996. Primary Contacts: Dr. Leroy Simmons, Dr. Henry Lewis, Dean

FAMU is actively pursuing several telemedicine-related technologies and applications simultaneously. The attached one-page summary entitled "Florida Agricultural and Mechanical University Campus-Wide Telecommunications and Information Technology Project" describes the complete networking of campus facilities; provision of personal computer workstations to each faculty member and staff; equipping of instructional laboratories, and adaptation and incorporation of up-to-date classroom instruction systems based on the latest computer and communications technologies.

A considerable amount of state level support is being made available for this and related projects for both planning grants and equipment to higher educational institutions throughout the state university system. More than $12 million in state funds have been allocated to connect all classrooms in the state to the internet using high speed connections under the "Florida Information Resource Network".

While the FAMU Ag Department is the "center" for Video Teleconferencing, the Pharmacy School is discussing using these facilities to link with its Tampa and Miami extensions to (among other things) do clinical rotations and practicums. Presently faculty and other meetings take place in person or using audio conferencing VTC would significantly help reduce the expense associated with long drive times and other inputs. The Ag department uses CLI Radiance compressed VTC equipment via T-1 connectivity under an USDA grant.

Another initiative being developed involves an electronic classroom in a trailer for both faculty development and math/science tutoring for students. The trailor has been outfitted with a Novel LAN and 50 workstations and is hooked up to the new computer lab at the pharmacy school.

In addition, a grant has been submitted to the state which, among other things, would include funding for an satellite uplink for programming with University of Florida and six or seven states to do programming in food, nutrition and the environment. This project will also involve pharmacy programming.

There are several downlinks including one at the media center which has been developed with funding from the Department of Defense for compressed video classes across several different departments including pharmacy. In addition, a PictureTel room-based VTC unit and a desktop unit are being installed for use over ISDN lines at the Career Development Center.

Efforts are also underway to equip the production studio for microwave hookup to the statewide PBS system. Recently, FAMU acquired a cable access channel within the city of Tallahassee to use for student news segments, population-based health announcements and stories etc., and there is interest in upgrading this channel for statewide activities.

The Pharmacy College's computer lab is well equiped with about 25 IBM 750s which are multimedia capable, a Mac to run the Adam animated discretion program for anatomy training and a considerable level of other software, all of which will be connected to the University's fiber backbone. A health informatics management lab is being developed to give training in electronic data exchange of simulated medical records.

CPSC staff also visited a cooperative extension teleconference center funded thru Title III of USDA for satellite downlinking and interactive VTC using a parsed T1 line.

It should also be noted that pharmacy college is developing a mock retail pharmacy which will allow training in computer processing of prescriptions and other possible telecommunications applications.

By virtue of its status and resources, FAMU is uniquely positioned within Florida to provide graduate degree programs within 18 N.W. counties and plans to use its emerging satellite and other telecommunications capabilities to extend offerings for Pharmacy degrees.

FAMU is also discussing linkages with four community colleges to produce course content and remote programming in places like Perry and elsewhere where there is a high demand.

It is anticipated that completion of a new Health Research Facility being constructed next door to the present pharmacy college will help drive the coordination of the several telecom efforts taking place across the campus.

Long-term, the college is interested in pursuing opportunities to provide lectures, seminars and other joint programming in a collaborative manner with other MHPF member institutions. The college also views the growing need to extend its PharmD program in and outside of Florida, and envisions other innovative use of telecommunications including the provision of pharmaceutical information to seniors and others through kiosks in retail pharmacies. Finally, FAMU would like to continue working to ensure the success of the Toxicology Outreach Network program.

Hampton University College of Health

Visited November 20, 1996. Primary Contact: Geeta Chandran, M.D., Assistant Provost for Health

Hampton University is the newest member of the Minority Health Professions Foundation. At this point, most of the information technology programs on campus have been developed by and for the broad University population, in particular the physics department which seems to be the premier department at the University. There is $5 million in funded research and 20 million in the entire research budget. There is a desire to increase activities in the College of Health and that is one of the main reasons that the assistant provost is an M.D. whose objective is to increase the focus on health programs at the University.

Hampton University's electronic access and media facilities are modern and are ubiquitous throughout the campus. There are two programmatically and technologically separate networks through out the campus: an academic/student network and an administrative network. The academic network includes an Intranet capability through which students can access Hampton's home page with links to information about admissions, course registration, housing, billing, etc.

A dedicated 56 KBPS line permits access to and use of Medline and is located at the library in a suite with 52 student workstations. The Computer science department also has a 30 seat "Gateway" computer lab where they teach intro to computers and a 40-seat "Sun" workstation lab that is open to students from 7AM to 12 Midnight seven days per-week. All students who enroll are provided access to Internet.

Though it has not been used to date for health applications, the University owns and operates a Cray supercomputer which was purchased by the Physics department under a grant from the Department of Energy.

Hampton University also has a satellite uplink and downlink on campus as well as video/media production facilities, and there is an initiative with Cox Cable for regional cable television programming.

Hampton University has committed itself to a major initiative to set up a four-year baccalaureate degree program in St. Kitts in the Eastern Caribbean. Many of the courses will be delivered via satellite from Hampton University. HU plans to begin offering courses in September of 1997 contingent upon the availability of equipment in St. Kitts.

Howard University Colleges of Medicine

Visited: January 14, 1997

Primary Contact: Bryant H. Logan, Director, Division of Informatics, Howard Health Sciences Center

Howard University College of Medicine (HUCM) defines telemedicine as the integration of the physician/patient encounter, the patient record, telecommunications, and teleconferencing at remote sites relative to the physician, in the real time domain. Telemedicine can further be defined as the use of electronic signals to transfer medical information from one site to another. The technology used to perform telemedicine can range from a simple telephone, to satellites, to state-of-the-art video-conferencing equipment. Although the definition is broad, telemedicine is increasingly being used as shorthand for remote electronic clinical consultation and distant medical education.

HUCM distinguishes between "telemedicine" and "medical informatics", the latter of which is defined by Howard as " the integration of health sciences with information and information technologies, a new science resulting from the interwoven disciplines of medicine and information."

Currently the telemedicine at Howard University is based in a telemedicine suite at the Howard University Hospital Ambulatory Care Center. The telemedicine suite contains appropriate telecommunications links, electronic clinical test equipment, computer workstations, lighting, and furnishings to support telemedicine encounters.

Currently Howard's primary telemedicine activity is its T1 compressed video link with the Roy Schneider Hospital in St. Thomas US Virgin Islands (USVI) (funded by contract with the Roy Schneider Hospital) to:

a) Provide point-to-point communications between Howard University Telemedicine and the USVI;
b) To provide continuing medical education to the USVI via the telecommunications link; and
c) to develop protocols in various medica; disciplines for providing telemedicine services to the USVI

Telemedicine overall is relatively new and still in the development stages, but the Health Sciences Center reports that it has proposed that members of the house staff and physicians will come to the telemedicine suite for their telemedicine-related activities. The suite is staffed by a facilitator/scheduler whose responsibility it is to provide access to telemedicine resources and to schedule facility use. At this time, there is no cost recovery mechanism in place but this will be part of the long term strategy.

The Howard University College of Medicine relies on Howard University of much of its informatics infrastructure. The university has an FDDI ( Fiber Data Distributed Interface) ring on campus with nodes at each of the major building. The fiber optic cable bundle contains eighteen multi-node and twelve single-node strands. Nine hubs join the 100 MB per-second network which connects 62 buildings on the main campus. Howard University Network (HUNet), as this system is called, provides capabilities for campus-wide communications, including video, voice, data, and high resolution graphics.

The Howard University College of Medicine course in medical informatics is designed to teach techniques which will aid and assist medical and graduate students in the state-of-the-art computer applications in bio-medical care. HUCM is responsible for teaching the procedures of accessing, retrieving and utilizing the online database system of the Medical Literature Analysis and Retrieval System (MEDLARS) from the National Library of Medicine as well as other medically related databases located around the world thought Internet.

In collaboration with other academic institutions inside and outside of the MHPF schools, HUCM has, for about four or fine years, sponsored an outreach program in partnership with the National Library of Medicine and Oak Ridge Institute for Science Education (ORISE), in Oak Ridge, Tennessee. This program brings together at Howard each spring representatives from Delta

region Historically Black Colleges and Universities for a four-day intensive session which covers NLM's MEDLARS databases and principles of informatics.

Through a series of grand rounds, the clinical and house staff of Howard University Hospital is exposed to medical informatics. Topics have included Introduction to the Internet, MEDLARS, and Medline and the Internet.

Additionally, training has been held for students in a class for communications disorders in the Howard University School of Communications. This program is based on information retrieved from NLM's new database, Health Services/Technology Assessment Research (HSTAR and the other databases of NLM's MEDLARS.

Meharry Medical College

Visited: August 21, 1996. Primary contact: John Arrandondo, MD, Vice President for Health Services and Dean

Meharry Medical College is in the process of fully developing its electronic information system capabilities. The VAX campus computer network system is 10-20 years old and is significantly underutilized. Because of its age and "non-user friendliness" individual PCs are used more than the VAX even though the VAX is connected to the institutional database (it was estimated by one knowledgeable staff member that $250,000 is needed to upgrade the computer system).

The VAX was set up originally as a financial information/management system and has been used, secondarily, for administrative purposes. There is no pretense, however, that the system was designed for medical or educational purposes (although it could be useful for certain limited applications). The system is even managed by the Vice President for Business and Finance.

Users do have unique addresses, and can access the network throughout campus, but only on campus (there is no remote access to the system). Further, the campus the network is not connected to any of the affiliates or satellite programs (including the MetroGeneral Hospital).

Faculty who have their own PCs with access to the Internet can also link to the VAX system, but the VAX system does not have full (graphics) connection to the Internet.

The College president recently appointed a medical informatics task force, and there will be a "medical informatics conference" in the near future to educate faculty.

Each department has ben provided with a PC and modem so that they can begin to explore applications, and there are plans for a LAN that will link the PCs, not just the VAX system.

In the future it is planned that teaching faculty will be make assignments to medical students both with computers and traditional means so that students will learn how to use new information technologies. Learning and use of computers and information systems are considered so important that the school has also considered a financing program whereby all students would have (leased) a new PC each year; by tacking an additional +- $500 on student fees. This way all students will have their own computer that can be "plugged in" anywhere on campus and can be kept current each year.

In other plans on campus, the York Veterans Administration Medical Center (VAMC) is Meharry's largest affiliated hospital. York VAMC is in Murphysboro, TN and there are plans to set up a videoconferencing link. The Dean has initiated a telemedicine committee with the VA and also wants to explore "virtual" telemedicine applications for education and training.

The newest affiliated hospital is Blanchfield Army Community Hospital in Ft. Campbell. The Commander now has videoconference capabilities that he uses for administrative purposes and Meharry wants to try to expand this use for health services and training.

One of the biggest problems in the planning for health information system growth is that there is no institutional plan/direction that takes into account all technical (and programmatic) departments which include computers, telephones, compressed video, and full motion video.

Library is the place on campus that has the best and broadest assess to the Web (there are few departments that have full graphics connectivity, and some of those result from faculty or staff paying for personal access or through a grants (with represent the majority of funding for Meharry's information technologies...especially the "Centers for Excellence" program). Staffing for information technology/telecommunications projects also is mode possible, for the most part, from grant funding.

The Campus is served by one fixed Television Receive Only (TVRO), and one steerable TVRO terminal. These are hard-wire (coax cable) connected to the 4 lecture halls on campus and to the library. One telephone (no bridge) is used for audio interaction during the times (not frequent) when Meharry participates in video conferences using the TVRO.

There is a new compressed video codec on campus located in the library and there are hopes that its use will become regular, primarily for videoconferencing.

Meharry Medical College is also an educational resource to and participant in Project DIANE (the Diversified Information and Assistance Network) which uses digital public telephone

network and interactive video/multimedia computer technologies to support cooperative electronic alliances in education, community service and economic development within the state of Tennessee. Since 1992, Project DIANE has recruited and trained teachers, scientists, artists, librarians, community workers, business counselors and other service professionals in the use of emerging information technologies. The project has helped to electronically connect schoolchildren, college students, families, handicapped individuals, senior citizens, small businesses, and others to a variety of beneficial online learning resources, information and professional expertise. DIANE's current online membership consists of a diverse group of universities, schools, museums, libraries, neighborhood community centers, and business assistance organizations.

Meharry was a pioneer, of sorts, in the development of local access to medical literature. In 1990, the National Library of Medicine and Meharry's library joined on an initiative with two objectives:

1) To develop and implement strategies to facilitate access to medic`al literature for a group of health professionals in urban and rural Tennessee, and
2) To provide training in the use of GRATEFUL MED to Meharry Medical College facility, residents, and students to provide them with information skills on which to rely as practicing health professionals.

The project was carried out in two phases. The first phase concentrated efforts on the Meharry campus. Demonstration workstations were installed at the Office of the President, a general medical floor at Meharry/Hubbard Hospital, the Dental School, and the library. Laptop computers and portable printers were assigned to selected medical students rotating to family medicine or AHEC preceptors.

The second phase of the project emphasized establishing demonstration sites at the practice locations of health professionals serving poor or underserved populations in Tennessee. In all, thirty-two fiend demonstration sites were set up across the state. Project staff installed equipment and GRATEFUL MED, trained participants at their locations, and provided technical and search-strategy support. Nine sites were set up with PC-compatible desktop workstations and twenty-three participants were provided with laptop computers. Two of the sites were community hospitals, three were offices with a nurse practitioner, one was a dentist's office, and the remaining sites were physicians' offices. Additional interventions tested and evaluated at the field demonstration sites included providing fax machines, access to electronic mail, delivery of full-text documents, and CE credits for GRATEFUL MED training.

Through the course of the project, more than 400 people on the Meharry Campus were training to search NLM's databases using GRATEFUL MED. They included 59 faculty members, 270 students (including 72 dental students), 60 residents, and 20 other health professionals. Field demonstration sites were installed at thirty-two locations across Tennessee.

Morehouse School of Medicine

Visited October 2, 1996. Contact: Ms. Audria Fox, Interim Director Information Technology

Morehouse considers its telecommunications related efforts in their infancy. They are working to consolidate three departments: 1) Institutional Computer Networks, 2) Administrative Computing Services, and 3) Telecommunications into a single department on Information Technologies.

Currently, the school is using a PC (486) based LAN over a fiber network with about 200 connected faculty, administrators and some off-site dial-in remote access. Morehouse envisions improved linkages with Grady Hospital for assistance with residence training, S.W. Community Hospital where there is a staff and resident run family medicine clinic and residency program, and for its family practice plan.

While Morehouse has no clearly defined plans for the provision of telemedicine or related services, a room for telemedicine has been set aside, and Hewlett Packard recently donated $1 million to the school with up to $500,000 available for improving network infrastructure.

Morehouse's new dean, Dr, Nigel Harris is very interested in developing interactive computer capabilities for assisted teaching, and this may or not include VTC. Possible outreach applications of telecommunications include community health and prevention in conjunction with the AHECs, and linkages with primary care centers in South Georgia. An other possible application might include residency training at the Tuskegee VA in psychiatry, internal medicine, and surgery. Morehouse faculty presently rent vans to make the drive in person.

Originally, Morehouse plans to participate in the Georgia Telemedicine Network were slowed, but the school is now anticipating delivery of a videoconferencing system by Bell South which will include a room-based unit operating over ISDN/BRI lines with the support of Bell South.

The school uses fiber throughout its physical plant its data network, and will be looking at scenarios for an ATM backbone for eventual VTC work. There is also presently a dedicated T-1 link used to connect to the internet for BBN Planet.

A new research wing on the hospital will include an electronic classroom, though no plans were available at the time of the visit.

Morehouse does have its own home page on the World Wide Web, is involved with CDC and NLM in Toxnet and has several other important external research relationships which may be important from a content point of view to the development of new telecommunications capabilities. Morehouse is involved with the NASA Office of Life Sciences and Microgravity Applications in various "Decade of the Brain" projects, is developing a Minority Space Medical and Life Sciences Research Center, is an NIH Neurosciences Institutes, and is undertaking DoD research in familiy medicine.

Texas Southern University College of Pharmacy and Health Sciences

Tuskegee University School of Veterinary Medicine

Visited: September 4, 1996. Primary Contacts: James A Ferguson, DVM, PhD, MPH, Dean and T. Habtemariam, DVM, PhD, Professor of Epidemiology

One of the primary ways the Tuskegee works with other MHPF schools is as a participant in funded research. This collaboration often takes the form of providing lab testing because of the lab and animal testing facilities available, unique to MHPF and predominately Black educational institutions.

There are 50 infections that are unique to man; there are 200+ that are zoonotic, diseases and infections that are developed in animals and can be transmitted to man. Many new and emerging diseases are animal-man related. As America turns its focus increasingly to wellness, there will likely be a greater appreciation for veterinary medicine because of the increasing awareness of the disease potential resulting from animal/human interaction. With respect to this, information technologies play several important roles:

A goal of Tuskegee is to develop a course on Zoonoses that will become part of the curriculum of each of the minority health professions schools. Videoconferencing would be a good way to deliver and administer such a course.

Since in excess of 40% of Tuskegee graduates go into public health service, many in rural areas of the country, continuing education and continuing contact with graduates is important. Tuskegee's vision includes video conferencing and Internet links with graduates.

Since no other school has stepped forward, or has the resources to do so, Tuskegee is in a position to provide a unique set of services and information products to rural America, possibly through the U.S. Department of Agriculture's Rural Utility Service rural telemedicine grant program.

Closer to home, on campus, an objective of the administration is for each faculty member to have desktop access to Internet, via the vet school's Local Area Network. Further, a 64,000 square foot facility is scheduled for occupancy shortly. It will provide space for surgical suites and laboratories, and house the International Center for Tropical Animal Health which coordinates the schools activities in Africa, the Caribbean, and other parts of the globe (Tuskegee has collaborative programs with the US Agency for International Development: at Suez Canal University and in Tanzania). It will also house state-of-the-art computer resources which are managed by the school's Biomedical Information Management System (BIMS), a unique team of biomedical scientists, education specialists, computer programmers, and visualization experts whose objective is to set the pace for computer assisted education among all U.S. veterinary schools. The majority of health informatics/information programs in place at the School of Veterinary Medicine have been made possible or are supported by the faculty and staff of the BIMS department.

Most of the health information initiatives at Tuskegee have been in the area of health informatics. The University has developed an integrated School of Veterinary Medicine Library Information system (SVM-LIS) at T.S. Williams Veterinary Medical Library (TSWVML). The SVM-LIS started in April 1989 and was completed April of 1991. The automation of the T.S. Williams Veterinary Medical Library was made possible under the "Center of Excellence in Minority Veterinary Medical Education" grant.

The primary goals of the Tuskegee University Veterinary Medical Library are to improve and advance education in the School of Veterinary Medicine. The expected result of this plan is to utilize this Library Information System to manage and retrieve in-house and national academic, and biomedical information. The system was selected to be suitable to the needs of the Library staff for their daily activities, and the need of Library Patrons. Quite significantly too, the goal was to enable Veterinary Scholar/Scientist to access online Library Information System and external databases that can be downloaded to an integrated bibliography management system.

The School of Veterinary Medicine's Library Information System (SVM-LIS) components are integrated to meet the demands of patrons in the School of Veterinary Medicine. The system runs on Macintosh and MS-DOS based systems and includes on-line services, access to national on-line databases, electronic mail, access to NOTIS, Interlibrary loan via FAX, CD-ROM on-line searching (Macintosh-based CD-ROM and MS-DOS-based CD-ROM), and the School of Veterinary Medicine Library Automation and Management System (SVM-LAMIS). SVM-LIS allows patrons to search and browse through the Veterinary Medical Library collection, and other online databases. A HyperCard front-end makes it easy to launch applications, use SVM-LIS help option, SVM-LIS user guides, and other functions. The SVM-LIS is networked to a MicroVAX Server unit via Ethernet TCP/IP type protocols permitting communication and sharing or resources locally and nationally. The MicroVAX and other hard disk systems are linked using appropriate communications software.

Databases used by the School of Veterinary Medicine Library Information System resource include: MEDLINE, VETCD, BEASTCD, AGRICOLA, ERIC, AIDSLINE, POPLINE, TOXLINE, Life Science Collection, Drug Information Source, and POI-TOX. The School of Veterinary Medicine Library Information System is linked with the existing Biomedical Information Management System databases such as Clinical Information System Administrative Information System, Business Information System.

Tuskegee University is one of only ten universities, in the United States and England, to receive grants from the W.K. Kellogg Foundation of Battle Creek, Michigan, to create conference centers for continuing education. The $14 million grant from the Kellogg Foundation, together with grants from the US. Department of the Interior and the U.S. Department of Agriculture, made possible the development of a $25 million facility with an array of state-of-the-art electronic technology, including remote video broadcasting and satellite uplink and downlink capability. Although the School of Veterinary Medicine has used the facility only infrequently, the possibility exists for broader applications.

Xavier University of Louisiana College of Pharmacy

Visited on September 26, 1996. Primary Contact: Dr. Robert Thomas

Xavier program administrators and faculty view the ability to provide non-traditional PharmD training within and outside of Louisiana as a tremendous potential resource for the School. There is a high degree of interest in offering courses via distance education to pharmacy students as well as other health care disciplines including psychologists, psychotherapists and other clinicians who must know how to deal with drug interactions.

There is interest in developing VTC and other technologies for Xavier on the part of several departments including pharmacy, but only recently have key change agents within the school begun meeting to discuss various approaches. Potential applications include teaching and training including help with the non-traditional PharmD program in Baton Rouge and communications to various communities. Presently audio conferences, videotapes and in-person faculty travel are used in place of interactive video. Xavier Pharmacy School works with the Department of Mass Communications to develop programming for local area cable.

While Xavier can presently up-link programming which it produces (and maintains on videotape) via the state microwave system through an NOETC node and can downlink satellite signals through their dish, it has no direct up or downlinking capabilities of its own. Given present discussions about the future VTC at Xavier, discussions about direct satellite have been put on hold. Xavier's production capabilities also include CD-ROM.

A recent survey within the school demonstrates a high degree of interest in Internet technologies and applications for the Pharmacy School. Xavier technology staff have been experimenting with Internet Audio and are interested in split screen multi-media for interactive instruction including audio and text response by students at a distance.

One of the more active uses of telecommunications at Xavier is through the Drug Information Center which is located at the Tulane University Hospital and Clinic. The Drug Information Center uses computer modem hookups to provide information resources for students including several NLM (MEDLINE/MEDLARS) and private sector pharmaceutical databases. It also uses CD-ROM and Microfiche increasingly as a substitute for costly journal and other periodical subscriptions.

VI. Preliminary Recommendations

A. Opportunities for Collaboration (To be added following conference discussions)

1. Content areas which should be included (i.e PharmD and other course work; collaborative biomedical research; administration of MHPF projects and programs)

2. Organizations to be involved (i.e. State offices of health; federal agencies including DoD, NLM, VHA, NASA, CDC; private sector vendors etc.)

a. Federal agencies
b. Private sector vendors
c. State and academic institutions
d. Foundations
e. Membership organizations -- i.e. Minority Health Panel discussions regarding telecommunications at the HBCUs; American Medical Informatics Association; American Telemedicine Association etc.

B. Establishing a Telehealth Network

1. Considerations

a. Preservation of individual efforts and program direction -- adding value to existing institutional interests
b. Identification of monetary and personnel resource requirements for each institution and among the schools
c. Interoperabilty and scaleability of a system which may evolve over time
d. Working from a common denominator approach

(To be expanded following conference)

C. Internet Networking

A common focus of attention at each of the member-institutions of the Minority Health Professions Foundation is linking via the Internet. A similar situation as exists today among members of the Foundation existed in the early 1970s when various universities and research agencies fostered the development of gateways to bridge different networks rather than attempting the impossible task of converting all of them to a common operating system. The gateways used a common software protocol dubbed the Internet Protocol, or IP. Added to this was a protocol to control transmission, the Transmission Control Protocol, or TCP. Together they form the primary internetworking protocol used to connect computer networks worldwide.

The World Wide Web is a data access system that runs on the Internet. It permits access to "pages" of information that can contain text, graphics, audio, video, and references to other pages of information. Graphical "browser" software programs (i.e., Netscape Navigator and Microsoft Explorer) allow individuals, with the "point" of a curser and "click" of a mouse button, to move from page to page if information throughout the Internet.

Tomorrow, organized networking via the Internet could represent a dramatic, affordable step toward efficient collaborative information sharing while improving the ability of the Foundation and its members to fulfill their mission.

Phase I, First Step: Internet Parity among MHPF schools

For several MHPF member institutions Internet applications have rapidly become an integral part of standard operating procedure in administration, curriculum design, delivery of clinical services, and research. For others the potential benefits of Internet remain unrealized. The promise of collaborative networking among the minority health professions schools will not be realized until there is parity in access to and use of the Internet.

Each school should be encouraged to make an immediate commitment to acquire connectivity to the Internet, permitting students and faculty use of Email and World Wide Web services. For those schools without centralized information systems that serve the entire campus, a dial up service through a commercial Internet Service Provider might be a reasonable initial step. But keep in mind that, typically, with new and largely unfamiliar applications of information technology to become routine practice, they must be seamlessly integrated into everyday practice. Of critical importance when encouraging acceptance and widespread use of new technologies is the issue of the physical location of the equipment. Clinical and research faculty who already feel strained to meet their current every-day challenges might consider it an undue burden to be forced to use workstations that are located even "only a few minutes away." For this reason, a satisfactory solution may not be departmental network workstations, but rather connectivity of each individual PC on campus.

Schools are currently in different stages of connecting administrative and faculty offices, libraries and classrooms to a centralized information systems support unit. Where it is not already, this should be a priority, and each school should become a "node" on the Internet and, as some have already done, acquire a "domain name (address)," such as TSU.EDU which identifies Texas Southern University.

The Foundation, itself, should also secure a domain name, perhaps MHPF.ORG (identifying the Foundation as having organizational status on the Internet). The Foundation should also establish a Web Server and a "Home Page" on the World Wide Web. The Foundation would then be in a position to facilitate information sharing and collaboration between and among members and to carry on its clearinghouse function electronically.

It is reasonable at this point to interject a note of caution. the MHPF-Net should not be viewed as a one-stop-shopping channel where, if one waits long enough, any and all types of information will present themselves for the passive reader to capture. MHPF-Net, even at its best, will requireactive engagement of member-users. Improving the quality information and access to it will be the driving force of the MHPF initiative, but users of information will be providers of information as well. Although technology and software platforms and services are important tools to make this possible, they should be discussed in the context of improving access to quality information.

Phase Two: Enhanced Audio and Video Internet Networking

Internet Audio

Audio links of reasonable quality is currently possible, though generally limited to point-to-point communication, via the Internet between users whose PCs are equipped with software and hardware to receive calls. Audio packages for Internet communication can currently support voice communication, voice mail, answering machine, multiple caller handling and call blocking. Some also offer whiteboard and file transfer as well.

Many of these Internet "telephone" packages are free, and most work with standard PC sound hardware over standard modem or network connections to the Internet. Further, most of them support both real time interactive (full duplex) or send and receive (half-duplex) transmission. One of the current limitations to Internet phone communications is lack of interoperability of software. Though changes are coming, in most cases all users now have to use the same software package.

Software products include:
CoolTalk, by Netscape Communications Corporation
Intel Internet Phone, by Intel Corporation
Microsoft NetMeeting, by Microsoft Corporation
WebPhone, by NetSpeak Corp
IBM Internet Connection Phone, by IBM Corporation

Internet Video

Video communications is also available, currently, via the Internet, though it is in its infancy in terms of service quality using the low bandwidth that has made data communications (and, increasingly, audio communications) so popular and affordable. We would use the term "video communications" rather than "videoconferencing" to make the distinction that current use of Internet for video is not in the quality range that many health institutions and business users have become accustomed to using early and current generations of video compression products such as VTEL, PictureTel, and Compression Labs.

Though we believe that Internet will, in the future, support broader applications of video communication at reasonable quality, currently most video applications require "enhanced" telecommunications connectivity (ISDN at up to 128 Kbps, or T1 at 1.544 Mbps) to realize quality of service that make its use worthwhile for most health applications.

Most of the current Internet video software products work with standard video cameras and sound cards, and some of the software is even free.

Software products include:
CineVideo/Direct, by CineCom Corporation
Connectix VideoPhone, by Connectix Corporation
Enhanced CU-SeeMe, by White Pine Software, Inc.
VDOPhone Internet, by VDOnet Corp.

Phase III. (Optional) Dedicated Videoconferencing Network

If each institution were to approach videoconferencing for its own purpose the need for a common approach would be lessened. There are systems available which permit some latitude in linking with users of different hardware. If, however, the interest is to develop regular communications and programming between and among MHPF schools a strong case can be made for selecting a common technology. The benefits include both systems compatibility as well as the economy of a group purchase and shared training.

Dedicated videoconferencing facilities are significantly more expensive than Internet videoconference, but at this stage of technology development they would represent a higher order of capability, greater resolution of images, faster frame transmission rates, etc.

Although this report was not intended to review technologies with an objective of recommending one over another, it might be instructive to note the findings of such a study conducted by the Veterans Health Administration in 1994. The study was made my MIRMO with the objective of finding a more effective and efficient way to deliver advanced high quality voice, data, and video communications services for various VHA applications, many not dissimilar to those envisioned by MHPF.

All major manufacturers of codecs (coder/decoder) who produced integrated videoconferencing systems that met all VHA needs both current and future, were asked to participate in a demonstration of this technology. Three of the six manufacturers which met the preliminary considerations, participated. They were VTEL, Compression Labs Inc, (CLI), and PictureTel. Each system was provided for a thirty-day demonstration period at no cost to the VHA. During this period each system was evaluated. The evaluation was based on technical merits, users' reactions and evaluation, the maintenance and support associated with the product. There was also an extensive economic evaluation for each manufacturer and its product line.

The result of MIRMO's evaluation was a document detailing the performance of various videoconferencing systems for meeting purposes, system functionality, and capability to support other applications (e.g. telemedicine, distance learning). Though completed more than one year ago, the findings of this study continue, by-and-large, to be accurate. Recommendations of study, therefore, should be the basis for further near-term decision-making with regard to videoconferencing and are discussed, briefly, below.

The systems tested were the VTEL BK227, the CLI Radiance, and the PictureTel 4427.

The results of the evaluation highlights each system's strengths and weaknesses. At many lower levels of scrutiny the various systems and their vendors were quite similar in performance. However, in others areas there were clear lines of distinction between each vendor and their respective performances. In the end, VTEL and its product finished first receiving the highest possible overall rating. This score resulted from VTEL receiving the highest possible score in three of the four evaluation areas. PictureTel finished a very solid second, scoring a slight level below VTEL in three categories, while getting the highest possible score for the economic evaluation. CLI finished third with a mixture of ratings for various parts of the evaluation. Strengths included its outstanding video capability and relative ease of use. However, CLI exhibited poor performance with respect to product support, the most expensive line of products, and poor audio performance. These weaknesses lowered their overall score in the associated factors.

As a result of the evaluation, it was suggested the VHA installations obtain one of the following: the VTEL VP-125, BK-127 or BK235 systems. Included these items would be a video cassette recorder, additional microphones and either a projection screen monitor or several additional monitors. For telemedicine purposes, the system with the optional Pen-Pal package was recommended, along with the acquisition of electronic stethoscopes, skin scopes and film digitizers for full telemedicine capability.

In the cases where the acquisition of the recommended system is not possible, certain provisions were recommended for successful videoconferencing operation. The potential system must support the latest set of ITU-T H.320 family of standards for videoconferencing. Furthermore, the system must at a minimum transmit at rates up to 769 kbps. Any of the systems tested in this evaluation would meet these requirements and provide some more additional features and functionality.

Also instructive for the MHPF is the determination made by VHA regarding system cost. With respect to budget planning for a videoconferencing network, the report recommended setting aside a minimum of $80,000 per system. This figure included an amount of $48,000 for purchase of a fully functional system (the example used was the VTEL BK227), $10,000 for an inverse multiplexer, and $2,000 for circuit installation. The remaining amount would be set aside for the various room preparation action items and optional equipment. The total cost, therefore, for a network of videoconference facilities at each of the 9 MHPF institutions would be approximately $720,000, to which would have to be added transmission costs linking participating programs and campus networking costs.

C. Other recommendations

(To be expanded following conference)

VII. Next steps and Implementation Plan

A. Steering committee to pursue recommendations
B. Action plan -- goals, objectives and time line

(To be completed as a result of conference)

VIII. Conclusion and acknowledgments