Valley Telehealth Partnership: Telemedicine Readiness for the San Joaquin Valley

Valley Telehealth Partnership
Telemedicine Readiness Evaluation for the San Joaquin Valley

Sponsor:

Partners:

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 95344 Phone: (209) 756-7698 Fax: (209) 723-6450 http://naturalsciences.ucmerced.edu Produced By: Amy Mo at 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

Executive Summary
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 Bakers eld, 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 Valley’s 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 implementation 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 identi es - 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 Governor’s 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 Valley telemedicine users. UC Merced’s 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.
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T

he San Joaquin Valley region of California is undergoing rapid transformation with a population growth that is 65% higher than the state’s average and changing demographics. By 2020, the segment of population

Data were organized into ten key indicator categories: 1) the organization’s interest; 2) funding available; 3) patient volume; 4) patient payor mix for reimbursements; 5) external referral rate to specialists; 6) lack of access to specialists; 7) the range of specialty needs; 8) physical space availability; 9) variety of use of telemedicine equipment; and 10) the organization’s 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 e ectively 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 using T1 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 sta ng; • 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 a ordable access to specialists for low income patients, and dedicate time and resources to program training, development and management. Identi cation 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 bene t 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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Table of Contents
Executive Summary Project Area Project Background
Telemedicine Background 7 The UC Merced Telemedicine Project 8

1 5 7

Methods
Data Collection 10 Data Analysis 11 Scoring and Weighting of Indicators 14

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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 Site Readiness Questionnaire San Joaquin Valley Ranking Results Appendix C: Questionnaire Score Cards for Ranking Site Assessment Room Accommodations Network Accommodations

15 23 28 30 31 32

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List of Tables and Figures
Table 1: San Joaquin Valley Facts Figure 1: Percentage of Children (Age 0-17) living in Poverty in San Joaquin Valley Counties Table 2. Key Objectives of the Valley Telehealth Partnership Site Assessment Questionnaire Table 3: Indicators of Telemedicine Success Table 4: Link between Survey Questions and Indicators Figures 2a and 2b: Maps of Facilities Who Received and Responded to Questionnaires Figure 3: Level of Anticipated Monthly Financial Commitment Figure 4: Type of Facilities Who Responded to Questionnaire Figure 5: Average Daily Number of Patient Visits (% of Facilities per County) Figures 6a and 6b: Monthly Out-of-Town Referrals Reported (Average by County) Figure 7: Patient Follow-through Rates with Out-of-Town Referrals for Selected Counties Table 5: Top 10 Specialty Medicine Needs Reported in San Joaquin Valley Figure 8: Current Use of Potential Telemedicine Room Figure 9: Interest in Live Access to Interactive Continuing Medical Education for Physicians and Sta Figure 10: Current Type of Internet Connection Table 6: San Joaquin Valley’s Top Ranked Sites for Telemedicine Implementation Table 7: San Joaquin Valley’s Top Ranked Sites for Telemedicine Implementation Before Disquali cation Method Table 8: Summary of the Chosen Sites for Telemedicine Implementation Table 9: Common Reasons for the Failure of a Telemedicine System 4 6

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13 14 15 16 17 17 18 19 19 20 21

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Project Area
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 Bakers eld, is well known as an agricultural powerhouse, with $23 billion in agricultural value earned annually in the eight-county region.

Table 1: San Joaquin Valley Facts1
• Eight Counties

• 27,280 square miles; 17% of the land area of California • 3.87 million people;
>10% of California’s total population (2006)

• 1,543,700 employed people (2006) • up to 15.5% unemployed (2008)2 • $24,244 per capita income (county average, 2005)

The California population is growing faster than the rest of the nation, and the Valley’s population is growing at a faster rate than the state average. Through the year 2030, the growth rate of the region is projected to be 65% higher than the state average.3 The rapid increase is accompanied by changing demographics. The segments of population 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
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state average.5 The Federal Government’s 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 quali ed 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 Bakers eld), 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 Valley’s 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 international 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

All eight counties in the San Joaquin Valley have both geographic and population shortage areas for primary care physicians, dentists, and mental health professionals.

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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.
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Figure 1 PERCENTAGE OF CHILDREN (AGE 0-17) LIVING IN POVERTY, 2006
35%
32 30 28 28

30% 25% 20% 15% 10% 5% 0%

29

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Poverty is associated

with increased risk of exposure to environmental 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 providers are at a severe disadvantage in accessing health care.9

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Project Background
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 de ciencies in some areas. 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 revenue…and 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 successfully moved towards integrating a wide telemedicine network among di erent 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 bene ciaries in the state, also serves approximately 50 percent of the state’s population.18 In Oroville, a town in California’s Sacramento Valley, approximately 90 miles north of Davis and its surrounding communities, designated as a “health professional shortage area,”19 98 percent of the
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“The bene�its of telehealth technologies to the health-care system far outweigh the costs of implementation.”29

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 Children’s 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 number of 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 o ces across the US,” and concluded that “overall the bene ts 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
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 expansion 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.
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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, O ce 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 o ers 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 information that could be used to assist in prioritizing connectivity of sites, improve levels of readiness in key areas, and develop needed speci c 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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Methods
Data Collection
The overall goal of the San Joaquin Valley healthcare facility site assessments 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 di erent 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 Telemedicine 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 considerations 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 Bakers eld. 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.

Table 2: Key Objectives of the Valley Telehealth Partnership (VTP) Survey Questionnaires
1. Determine facility interest in using telemedicine 2. Determine facility needs for telemedicine, including expected utilization (volume and type) and speci c specialist provider needs 3. Better understand the operating environment that exists for SJV facilities 4. Determine facility’s current level of readiness to apply/use telemedicine 5. Identify variables important for development of a connectivity and implementation plan.
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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 facility’s ability to house a telemedicine program. Speci cally, the survey covered two key technical areas: physical accommodations and networking accommodations. Data on the size, accessibility, noise levels, privacy issues, décor, lighting, availability, etc. characteristics of the room identi ed by the provider for telemedicine were collected. Data were collected on the facility’s current network con guration 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 e cient manner, while automatically alerting the project manager when an update to the database has occurred.

Data Analysis
Healthcare facilities were ranked using ten speci c macro indicators associated with successful implementation and sustainability of telemedicine programs. These indicators were derived from shared experiences of telemedicine 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).

Indicators

1

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-speci c 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.

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2

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 allocate reasonable amounts of internal funds to continue the program after grants expire.

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PATIENT VOLUME Previous research has shown that a telemedicine system will fail if the service is not needs-driven. Since the San Joaquin

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 nancially sustainable program.

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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.

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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 de cit 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.

in creating sustainable telemedicine programs. A facility poised to increase access using telemedicine should be making external referrals outside of their community in an e ort to accommodate their patients’ care needs. Greater volume helps to bu er the costs associated with sta ng and program maintenance in telemedicine, so clinics with low out-of-town referral rates will likely have more di culty 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 e ective way via telemedicine.

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EXTERNAL REFERRAL RATE Current referral rates are often good predictors of a clinic’s potential success

Criteria for Telemedicine Success:

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RANGE OF SPECIALTY NEEDS Multiple medical specialty needs (by referring sites) are predictive of facilities that are likely to

• Organizational Capacity • Medical Needs

utilize telemedicine. These sites for telemedicine are likely to become

• Technical Capacity
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sustainable over time, due to the “holistic” utilization that would grow within an organization. Diversity of referrals provides added strength.

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APPROPRIATE PHYSICAL SPACE Unmanaged technical problems can be barriers to utilization of telemedicine. The environment must support proper use of technology and e cient work protocols, such

as limiting disruptions or disturbances. Facilities must have access to an adequately sized, under-utilized and conveniently 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 connectivity, appropriate lighting for optimal teleconferencing sessions, acoustic quality, etc.

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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 bene ts 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 bene ts 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 bene t/cost ratios.

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TECHNOLOGICAL FAMILIARITY Current use and familiarity with internet based applications in day-to-day work ows (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 implementation than those that lack this familiarity.

Table 3: Indicators of Telemedicine Success
Criteria Organizational Capacity Indicator Organization’s Interest Funding Available Patient Volume Patient Payor Mix for Reimbursements External Referral Rate Lack of Access to Specialists Range of Specialty Needs Physical Space Availability Variety of Equipment Usage Technological Familiarity and Capacity Code Interest Funding Volume Reimbursements Referrals Specialists Range Space Equipment Technology Weight 15 15 5 8 10 10 7 15 10 5 100%

Medical Needs Technical Capacity Total

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Scoring and Weighting of Indicators
For each individual question, a number of points were allocated to speci c 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 this question was allocated 5 points, while an answer of “no” was not allocated any points (zero). The questions were then grouped together by indicators 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.

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 speci c questions were identi ed as absolute prerequisites for the selection criteria; therefore, if the facility answered in the negative to any one of those 9 questions, they were classi ed as ‘not currently ready’ due to a lack of having key components in place.

Table 4: Link between Survey Questions and Indicators
Indicator Code Total Number of Questions
(from 3 surveys)

Maximum Total Points Allowed

Maximum Points Earned
(speci c to this data set)

Number of Disqualifying Questions
(automatic zero for that indicator)

Maximum Weighted Points

Interest Funding Volume Reimbursements Referrals Access Specialty Space Equipment Technology Total

8 12 6 1 1 7 1 26 2 10 74

20 45 25 6 5 25 7 133.5 10 32 308.5

20 42.5 25 6 5 21 7 121.25 10 32 289.75

4 2 -----3 --9

15 15 5 8 10 10 7 15 10 5 100

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Results
The response rate of health care facilities to both surveys was approximately 63 percent. The site assessment questionnaire was completed by 84 of 133 San Joaquin Valley clinics and hospitals in the Stockton to Bakers eld 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.

Figure 2a DISTRIBUTION OF HEALTH CARE FACILITIES IDENTIFIED AND RECEIVED FIRST QUESTIONNAIRE (N=133)

Figure 2b DISTRIBUTION OF HEALTH CARE FACILITIES THAT RESPONDED TO BOTH QUESTIONNAIRES (N=47)

All sites were noti ed at the outset that UC Merced intended to use the information to assist in creating an eHealth network for the San Joaquin Valley. Furthermore, those sites that received the second survey were also noti ed that the University anticipated augmented funding for the purchase of additional telemedicine equipment (Proposition 1D), and that the survey would help the University determine which San Joaquin Valley 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.
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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 understa ed, 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 speci c information requiring considerable time and e ort 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 state’s budget crisis – may have simply felt too overwhelmed by budgetary issues to commit to starting anything new when the second survey 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.

FINDING: The majority of surveyed health care facilities in the San Joaquin Valley are interested in implementing telemedicine. FINDING: Most facilities in the San Joaquin Valley would be interested in starting a telemedicine program now if they could a ord to do so.

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 facility’s operations. 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.

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 telemedicine 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 respondents 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 .
$600 - $1,200
4%

Figure 3 LEVEL OF ANTICIPATED MONTHLY FINANCIAL COMMITMENT
$2,600 and up
2%

$1,300 - $2,500
15%

None
28%

$200 - $500
51%

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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 signi cant challenges in providing mental health services to their patient base, only one percent of the facilities responding to the survey were speci cally dedicated to providing behavioral health.
Rural Outpatient Clinic 55% Urban Outpatient Clinic 26% Rural Hospital 18%

Figure 4 TYPES OF FACILITIES WHO RESPONDED TO QUESTIONNAIRE
Rural Behavioral Health Clinic 1%

Reimbursements
Facility designation as a Rural Health Center (RHC) or Federally Quali ed Health Center (FQHC) is important when considering reimbursement rates and the population served. As reimbursement rates are typically higher for facilities with these designations, RHC and FQHC facilities have larger pro t 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 o cially considered 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.
40% 20% 0%
as er lav Ca

FINDING: Multiple clinics have su cient patient volume to support a sustainable telemedicine program.

Figure 5 AVERAGE DAILY NUMBER OF PATIENT VISITS (PERCENTAGE OF FACILITIES PER COUNTY)
100% 80% 60%
1,000-1,499

500-999 100-499 0-99

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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 re ects 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 substantially di erent as is the patient volume at the responding clinics. The lack of specialists operating within these counties contributes to a signi cant 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.

Figure 6a MONTHLY OUT-OF-TOWN REFERRALS REPORTED (AVERAGE BY COUNTY)
200
189.2

Figure 6b MONTHLY OUT-OF-TOWN REFERRALS REPORTED, PER 100,000 POPULATION
150
Number of Out-of-Town Referrals per 100,000 Population

120

150
Average Number of Out-of-Town Referrals
102.5 102.5

90

100

60

50
10.0

35.5 18.8 10.0 25.0

30.0 8.3

30

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

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Follow Through Rates
Patient follow-through rates with out-of-town referrals are a component of patient care outcomes. The frequency with which San Joaquin Valley patients are able to follow through with referrals to out-of-town specialists is useful to assess the potential impact of telemedicine in Valley regions, and to provide baseline information for future comparisons (post telemedicine), and site prioritization strategies. In Merced County, about 80 percent of referred patients follow through on out-of-town referrals less than 25 percent of the time. Fresno County facilities report higher follow-through rates than Merced County with approximately 54 percent of patients following through 50 percent or less of the time. Kern County estimates that nearly two-thirds of patients receiving an out-of-town referral follow through 25 percent of less of the time. Tulare County reports that approximately 75 percent of referred patients follow through at least 50 percent of the time or better. These data suggest that patient follow-through rates on out-of-town medical referrals are low in counties where patients must travel to see a specialist. Followthrough with specialists is anticipated to improve markedly with telemedicine, because more patients will consult with specialists while remaining in their own communities.
20% 0% 80% 60% 40%

Figure 7 PATIENT FOLLOW-THROUGH RATES WITH OUT-OF-TOWN REFERRALS FOR SELECTED COUNTIES
100%
76 - 100% 51 - 75% 26 - 50% 11 - 25% <10%

Limited Specialty Access
The overwhelming majority (89%) of facilities in the San Joaquin Valley reported that gaining access to medical specialists for their patients is a problem. For the most part, private practice specialists are currently unable to accommodate Medi-Cal or Medicare patients due to unpro tably low reimbursement rates and laborious paperwork requirements.

Fresno

Kern

Merced

Tulare

Table 5: Top 10 Specialty Medicine Needs Reported in San Joaquin Valley
1. Cardiology 2. Dermatology
3. Psychiatry

(73%) (71%)
(46%)

4. Pediatric Specialties (42%) 5. Gastroenterology 6. Orthopedics 7. Neurology 8. Psychology 9. Radiology 10. Obesity (33%) (31%) (25%) (21%) (19%) (13%)
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Range of Specialty Needs
The ten most commonly reported urgent needs for specialty medicine in the San Joaquin Valley are listed in order of reported need in Table 5.

Physical Space
The proper physical environment to install and use the technology in a patient care setting is critical for a sustainable telemedicine program. Four (7%) sites reported having more than one room that could be used for telemedicine. However, only 7 (13%) expected that a speci c room could be used full-time for telemedicine. 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 combinations, 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. Therefore, 20 percent (11 out of the 54 total rooms reported) automatically do not meet the minimum requirements for their speci c room to be used for telemedicine. This data are helpful in determining the costs associated with room preparations (lighting, wall color, sound panels, etc.) and connectivity accommodations for each site.
Barrier to Utilization of Outpatient Telemedicine May Present Some Problems for Telemedicine Highly Satisfactory to Support Telemedicine
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Figure 8 CURRENT USE OF POTENTIAL TELEMEDICINE ROOM

Emergency, Triage, or Surgery Rooms 20% Adminstrative/Office, Exam, or Proceedure Rooms 24% Patient Consult or Not in Use 56%

Variety of Equipment Usage
Approximately 90 percent of San Joaquin Valley sites reported that they are primarily interested in conducting outpatient 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 would be interested in accessing these educational bene ts weekly or biweekly.
sted tere ot In N 11%

Technology
The results of the technological readiness questionnaire 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 implemented 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 expectations. Even though a small number of survey questions 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 networking equipment – UPS, routers, and switches – 91 percent were able to identify their preferences.

Figure 9 INTEREST IN LIVE ACCESS TO INTERACTIVE CONTINUING MEDICAL EDUCATION FOR PHYSICIANS AND STAFF

Interested 89%
Annually Quarterly 2% 5%

Unsure 14% Monthly 29%

Weekly 26% Biweekly 24%

Figure 10 CURRENT TYPE OF INTERNET CONNECTION
HDSL 4 mbps 2% Fiber 9% DSL/Cable 13% DSL/Cable 13% Satellite 2%

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 percent.

10 med DSE3 18%

T1 Line 56%

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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.

Table 6: San Joaquin Valley’s Top Ranked Sites for Telemedicine Implementation
(out of 54 sites)

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 key component, which ultimately disquali ed 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

Rank

Clinic Code #

Location – County
Fresno Kern Kern Fresno Kern Fresno Fresno Kern Kern Kern

Final Total Score
(out of 100 points)

1 2 3 4 5 6 7 8 9 10

16 37 36 12 23 15 14 21 24 9

70.0 68.0 65.6 65.2 64.4 62.6 59.4 59.4 59.4 59.4

KEY FINDING: Overall, the data regarding facilities’ readiness shows that the real barrier to adopting telemedicine successfully in the San Joaquin Valley is economic.

criteria.

Table 7: San Joaquin Valley’s Top Ranked Sites for Telemedicine Implementation Before Disquali cation Method
Transitional Rank
(out of 54 sites)

Clinic Code #
3A 26B 43 37 29 16 34 30 47 26A

Location – County
Tulare Stanislaus Tulare Kern Kern Fresno Kern Kern Tulare Stanislaus

Transitional Score
(without disquali ers)

Missing Key

Component(s)
Space Space Funding N/A Space N/A Space Space Funding Space
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1 2 3 4 5 6 7 8 9 10

91.2 89.3 86.3 85.7 85.4 84.5 84.0 83.1 82.6 82.6

Discussion
Although telemedicine has the potential to improve health care access and have economic bene ts for individual and the community, there are a number of common challenges identi ed 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 readiness 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 signi cant, 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 telemedicine, a lack of time or resources to complete the survey, and/or confusion regarding the various telemedicine surveys, as multiple inquiries and e orts 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 8: Summary of the Chosen Sites for 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 their reimbursements from private insurance, and about 25% from Medi-Cal (signi cantly higher and lower, respectively, than the average from the sample) Referrals ~ They currently make about 65 out-of-town referrals monthly Access ~ Their highest specialty needs are for cardiology, nutrition, dermatology, allergy / immunology, and psychology Specialty ~ They have an interest in using telemedicine for outpatient specialty consults Space ~ They have appropriate space to house the project, 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, teleradiology, teleophthalmology, telepharmacy Technology ~ They may have some upfront costs to set up the room, such as putting a phone line, computer jacks and UPS in the networking room, but they have the capacity to do so

Table 9: Common Reasons for the Failure of a Telemedicine System33
• • • • • • • • the service was not needs-driven there was no commitment to provide the service there was no suitable exit strategy after research funding expired there was poor communication there was a lack of training there were technical problems work practices were not updated the protocols for use were poor or non-existent

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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 California’s deteriorating nancial situation have begun to negatively a ect many safety net facilities and could soon render some of the San Joaquin Valley’s higher ranking sites unable to a ord 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 implementation planning, in order to con rm their ability to support a program.

Many San Joaquin Valley facilities are open to using technology.

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 speci cally asked in the questionnaire, 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.

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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 e ectiveness 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 accommodate 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 interviews with 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 a ordable 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. In order for telemedicine to bene t 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 a ord the discounted fees o ered 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 bene t the San Joaquin Valley for the long-term. Additionally, because telemedicine is typically not a pro table 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 e orts will have similarly short lived life spans to those which failed. Due to its nancial complexities and severe problems with accessing

The top challenge is affordability.

medical specialties, the San Joaquin Valley provides a challenging realworld 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.
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Reported Referral and Follow-through Rates:

Interestingly, there were county-speci c di erences 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 County’s 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 followthrough 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 site’s 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 complete 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.
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Most facilities are not familiar with the requirements involved in generating high-quality outpatient telemedicine consultations, so speci c details were gathered about each of the facility’s potential rooms and their locations in order to properly evaluate their appropriateness 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 con dentiality. Facilities suggesting the use of these types of rooms for telemedicine would need to nd better suited spaces 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 modi cations 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 a ord 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 modi cations 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.
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San Joaquin Valley facilities are already investing in the human aspect of their technology infrastructure.

Recommendations and Summary
Telemedicine Doesn’t 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 a ord 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 pro table, 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 a ordability 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 specialists 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 income populations. Rather than try to convince non-interested groups otherwise, e orts should instead be focused on those who are interested. Physicians who are attracted to exible working conditions, 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 the overall future of telemedicine.

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2. Healthcare is a business. Therefore, pro tability is important. All
planning for telemedicine should center around creating value that can be measured by enhanced pro tability. For instance, a program that helps surgical specialists remotely screen incoming referrals can result in more surgery time and less un-pro table, expensive (high operational costs) o ce consults. Post operational check ups could be handled similarly, saving time and money. The business model on the specialist’s 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 relationships with specialists who are interested in using telemedicine and who can do so pro tably 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 be developed so that e ective 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 Valley’s 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 are a ordable 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 sta ng, etc. will be needed; 2. O er 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 organization’s pro tability. 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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Conclusion
The 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 a ordable access to specialists for low income patients, and dedicate time and resources to program training, development and management. Identi cation 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 bene ted 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 o er little bene t to patient care overall.

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Endnotes
1. California Department of Finance, California County Pro les (2007) 2. State of California, Labor Market Information Division, (last viewed December 19, 2008) 3. California Department of Finance, California County Pro les (2007) 4. California Health Interview Survey (2007), UCLA Center for Health Policy Research 5. RAND California Database, 2007, using HCFA Medicaid Statistics 6. California Health Interview Survey (2007), UCLA Center for Health Policy Research 7. California Health Interview Survey (2007), UCLA Center for Health Policy Research 8. Suk WA. 2002. Beyond the Bangkok Statement: research needs to address environmental threats to children's health. Environ Health Perspect 110:A284-A286 9. National Standards for Culturally and Linguistically Appropriate Services in Health Care. Report for U.S. Department of Health and Human Services, O ce 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 Med 2001; 38: 323-7. 12. Blumenthal D. New steam from an old cauldron: the physician supply debate. N Engl J Med 2004; 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 bene ts of telemedicine. J Telemed Telecare. 2002; 8 (Suppl. 1):1-30; and Hailey D, Ohinmaa A, Roine R. Study Quality and evidence of bene t in recent assessments of telemedicine. J 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 hospitals. Pediatrics. 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 trial of 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.105:843-847. 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 services. J Telemed Telecare. 2005;11 (Suppl.1): S1:3-4.
31

APPENDIX A:
Valley Telehealth Partnership Questionnaires
Site Assessment Questionnaire Site Readiness Questionnaire

32

UC Merced’s Valley Telehealth Partnership Questionnaire
The purpose of this questionnaire is to assess your facility’s level of interest in becoming a telemedicine partner with UC Merced in its Valley Telehealth Partnership program. Please answer all of the following questions to the best of your ability and forward the completed survey to 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? Is your location considered rural or urban? Are you a recognized FQHC facility? Please circle the best description/s of your facility below:
Hospital (in/out patient services) Outpatient Clinic Behavioral Health Clinic

Yes Rural Yes

No Urban No

Please circle the best description of your provider type below:
Community Health Clinic Non-Profit Hospital Mental Health Clinic For-Profit Hospital Rural Health Clinic Other: ______________

Are you interested in using telemedicine at your facility?

Yes No If no, why not? _________________________________________________________
If yes, which uses are you most interested in? (Circle all that apply)
Outpatient Specialty Consults E/R Consults Tele-cardiology (store/forward) Tele-fetal monitoring Distance Continuing Ed Tele-radiology Tele-ophthalmology Patient Monitoring (real time) Inpatient Specialty Consults Tele-pharmacy Tele-Ultrasound Other: _____________________

What is your clinic/facility’s daily visit average? ___________________________________ What is your clinic/facility’s 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 ______% Private Insurance _______% Medi-Cal _______% Medicare ______ % Other:__________________

Which five specialty referrals are most commonly needed by patients seen in your facility? (Please number 1-5 in order of perceived need; 1= highest need) ___allergy/immunology ___ burns ___cardiology ___critical care ___dermatology ___endocrinology ___gastroenterology ___hematology ___neurology ___nutrition ___obesity ___OB/GYN ___oncology ___orthopedics ___pediatric specialties ___pulmonologist ___psychology ___psychiatry ___radiology ___rheumatology ___Other: _________________

Is gaining access to medical specialists a problem for your patients? Yes

No

How many out of town referrals to medical specialists are you making per month? _______ How often do you estimate your patients are able to follow through with referrals to out of town specialists? (circle best answer)
Less than 10% 11-25% 26-50% 51- 75%, 76-100%

How often do you estimate these patients return for the necessary follow up care?
Less than 10% 11-25% 26-50% 51- 75% 76-100%

Telemedicine technology enables primary care physicians in rural or underserved communities to connect their patients with out-of-area specialists in real time consults, or via store and forward capabilities, allowing for convenient, local access to specialty healthcare. In your opinion, is this something your patients and facility would benefit from Yes No using? Based on the current needs of your facility, what would you estimate your monthly use of telemedicine to be (# of consults)? ___________________________________________ Would live access to interactive continuing medical education (such as patient rounds) for Yes No your physicians and medical staff be of value to you?

How often would you or your staff be interested in accessing educational benefits? _______________________________________________________________________
Do you think that the physicians at your facility would be interested in using telemedicine?
Yes No Not Sure

If telemedicine were provided by your facility, would you be interested in educating your Yes No community about the benefits of telemedicine? Are you willing to providing periodic telemedicine demonstrations to patients in order to Yes No raise awareness and increase utilization of telemedicine services? Is your clinic/facility willing to commit some staff time to the training required to use Yes No telemedicine successfully? Is your clinic/facility able to commit some of its financial resources to the continuing Yes No operating costs required to sustain a telemedicine program? Please specify the level of financial commitment you anticipate being able to provide per month: (costs may include: connectivity, video conferencing time & some staffing time)
None $200-500 $600-1200 $1300-2500 $2600 and up

Is your clinic/facility willing to provide UC Merced with non-confidential (no patient No identifying data) utilization reports on an ongoing (monthly) basis? Yes Is your clinic/facility willing to remain in regular contact with UC Merced’s Telemedicine Yes No Project Manager in order to ensure program success? Do you currently have an internet connection at your clinic/facility? Yes

No
Cable

If yes, how do you connect? (circle one):

Modem/Dial Up

DSL

Do you currently operate on a wireless network?

Yes

No

********************************************************************** Thank you for your participation in UC Merced’s Valley Telehealth Partnership survey. As a survey participant, you will be notified in writing when UC Merced has selected its Valley Telehealth Partners. Between now and then, we may contact you for more information regarding the information you provided in this questionnaire. For questions regarding UC Merced’s telemedicine project, or this questionnaire, please contact Jennifer Smith directly at: [email protected] , or via telephone at: (209)756-7698.

UC Merced Valley Telehealth Partnership Site Readiness Questionnaire
Section 1: Telemedicine Physical Room Accommodation
Please answer the following questions to the best of your ability for each room that you feel could be considered for the use of telemedicine. If you have only one room to consider, please skip to section 2 below after completing your information for the first room. Room 1 01. Do you have a 10 x 10 or larger room that maybe designated for telemedicine 30% or more of the time? Yes No

1a. If so, please note the room’s measurements:

Х 02. Approximately how often would you expect this room to be available for the purpose of telemedicine consults? % of time

03.

How is this room currently used? Not in use Patient Consult Triage

Surgery room

Admin/office Break

Other (specify): ________ 04. Is this room located next to any busy areas with lots of noise? Yes No

05.

What types of rooms are located next to this room? Waiting room room Lab Consult

Triage room Break room Storage

Cafeteria (specify): 06. The following will require that you go into the room, close the door, and evaluate the following: 6a. Quietly listen for noise for 30 seconds and check off any of the following sounds that you hear:

Other

Voices Fluorescent lights

Plumbing Air/heat noise

Music None

Other (specify): 6b. Now clap your hands several times, do you hear an echo in the room? Yes No

07.

Is this room conveniently located for physicians to use regularly throughout the day (within 5 minute walk or less)? Yes No

08.

Does the room have windows?

Yes

No

8a. If so, are there window coverings?

Yes

No

09.

Does the room have patterns on the wall (i.e. wall paper)? Yes No

9a. What color are the walls?

Please describe:

9b. Is the paint in good condition? Yes No

10.

What type of flooring is in this room?

Hardwood Carpet Linoleum Cement Other Overhead fluorescents: # Desk lamp: # Standing torch light: # Gooseneck: # Other: # #

11.

Light sources (check type of light and note how many of each are located in the room).

12.

How many electrical outlets are in the room?

13.

Is there a phone jack/line available?

Yes

No

13a. Can it be used for telemedicine purposes (incoming/outgoing calls)?

Yes

No

13b. If not, can another phone line be brought in?

Yes

No

14.

Are there any computer (networking) jacks located in the room? Yes No

14a. How many? #

15.

Are there any permanent furnishings (sinks, counters, cabinets, tables, etc.) located in the room? Yes No

15a. If yes, please specify and note the measurements of each:

Counter Cabinet Other Sink Table Other:

W W W W W W

xL xL xL xL xL xL

xH xH xH xH xH xH

16.

Is there a phone jack/line available? Yes No

16a. Can it be used for telemedicine purposes (receiving incoming/making outgoing calls) Yes No

16b. If not, can another phone line be brought in? Yes No

If you have additional rooms you would like us to consider for your telemedicine program, please continue adding rooms below; if not please skip to Section 2. Room 2 01. Do you have a 10 x 10 or larger room that maybe designated for telemedicine 30% or more of the time? No Yes

1a. If so, please note the room’s measurements:

Х 02. Approximately how often would you expect this room to be available for the purpose of telemedicine consults? % of time

03.

How is this room currently used? Not in use Patient Consult Triage

Surgery room

Admin/office Break

Other (specify): ________ 04. Is this room located next to any busy areas with lots of noise? Yes No

05.

What types of rooms are located next to this room? Waiting room room Lab Consult

Triage room Break room

Storage Cafeteria (specify): 06. The following will require that you go into the room, close the door, and evaluate the following: 6a. Quietly listen for noise for 30 seconds and check off any of the following sounds that you hear: Other

Voices Fluorescent lights

Plumbing Air/heat noise

Music None

Other (specify): 6b. Now clap your hands several times, do you hear an echo in the room? Yes No

07.

Is this room conveniently located for physicians to use regularly throughout the day (within 5 minute walk or less)? Yes No

08.

Does the room have windows?

Yes

No

8a. If so, are there window coverings?

Yes

No

09.

Does the room have patterns on the wall (i.e. wall paper)? Yes No

9a. What color are the walls?

Please describe:

9b. Is the paint in good condition? Yes No

10.

What type of flooring is in this room?

Hardwood Carpet Linoleum Cement Other Overhead fluorescents: # Desk lamp: Standing torch light: Gooseneck: Other: # # # #

11.

Light sources (check type of light and note how many of each are located in the room).

12.

How many electrical outlets are in the room?

#

13.

Is there a phone jack/line available?

Yes

No

13a. Can it be used for telemedicine purposes (incoming/outgoing calls)?

Yes

No

13b. If not, can another phone line be brought in?

Yes

No

14.

Are there any computer (networking) jacks located in the room? Yes No

14a. How many? #

15.

Are there any permanent furnishings (sinks, counters, cabinets, tables, etc.) located in the room? Yes No

15a. If yes, please specify and note the measurements of each:

Counter Cabinet Other Sink Table Other:

W W W W W W

xL xL xL xL xL xL

xH xH xH xH xH xH

16.

Is there a phone jack/line available? Yes No

16a. Can it be used for telemedicine purposes (receiving incoming/making outgoing calls) Yes No

16b. If not, can another phone line be brought in? Yes No

If you have additional rooms you would like us to consider for your telemedicine program, please continue adding rooms below; if not please skip to Section 2. Room 3 01. Do you have a 10 x 10 or larger room that maybe designated for telemedicine 30% or more of the time? Yes No

1a. If so, please note the room’s measurements:

Х 02. Approximately how often would you expect this room to be available for the purpose of telemedicine consults? % of time

03.

How is this room currently used? Not in use Patient Consult Triage

Surgery room

Admin/office Break

Other (specify): ________ 04. Is this room located next to any busy areas with lots of noise? Yes No

05.

What types of rooms are located next to this room? Waiting room room Lab Consult

Triage room Break room Storage Cafeteria (specify): 06. The following will require that you go into the room, close the door, and evaluate the following: 6a. Quietly listen for noise for 30 seconds and check off any of the following sounds that you hear: Other

Voices Fluorescent lights

Plumbing Air/heat noise

Music None

Other (specify): 6b. Now clap your hands several times, do you hear an echo in the room? Yes No

07.

Is this room conveniently located for physicians to use regularly throughout the day (within 5 minute walk or less)? Yes No

08.

Does the room have windows?

Yes

No

8a. If so, are there window coverings?

Yes

No

09.

Does the room have patterns on the wall (i.e. wall paper)? Yes No

9a. What color are the walls?

Please describe:

9b. Is the paint in good condition? Yes No

10.

What type of flooring is in this room?

Hardwood Carpet Linoleum Cement Other Overhead fluorescents: # Desk lamp: Standing torch light: Gooseneck: Other: # # # #

11.

Light sources (check type of light and note how many of each are located in the room).

12.

How many electrical outlets are in the room?

#

13.

Is there a phone jack/line available?

Yes

No

13a. Can it be used for telemedicine purposes (incoming/outgoing calls)?

Yes

No

13b. If not, can another phone line be brought in?

Yes

No

14.

Are there any computer (networking) jacks located in the room? Yes No

14a. How many? #

15.

Are there any permanent furnishings (sinks, counters, cabinets, tables, etc.) located in the room? Yes No

15a. If yes, please specify and note the measurements of each:

Counter Cabinet Other Sink Table Other:

W W W W W W

xL xL xL xL xL xL

xH xH xH xH xH xH

16.

Is there a phone jack/line available? Yes No

16a. Can it be used for telemedicine purposes (receiving incoming/making outgoing calls) Yes No

16b. If not, can another phone line be brought in? Yes No

Section 2: Telemedicine Network Accommodation
Please complete the following section regarding your facility’s network. Note that it may be helpful to have a member of your IT staff complete this portion of your survey. 01. Where is your network equipment located? Room Closet Other:__________ 1a. Is the air ventilated? Yes 1b. Is the space air conditioned? Yes 02. Who is your internet provider? Specify: _________ No No

03. Do you have an IT staff/team that is easily able to assist with troubleshooting/maintenance of your current network and equipment? Yes No

What kind of internet connection is being used? 04.

DSL/Cable Fiber

Dial up Other:

T1

4a. Please specify how much bandwidth is currently being used: _______________

05. If a T1 line must be brought into the building for Telemedicine use, where is its preferred placement? 06. Is there enough copper available (a minimum of two pairs of copper is needed) for a T1 line to be brought in for the use of telemedicine? 6a. Is there enough room for networking equipment (approximately 5 square feet)? 07. Is there enough space in the networking room for a new router? Yes 08. Is there enough space in the networking room for a new UPS? 09. Does the site have any preference on brands for the new networking equipment?
09a. If yes, please specify the brand preference with the corresponding type of equipment in the blanks provided

Wall

Rack

No space

Yes

No

Yes

No

No

Yes

No

Yes

No

UPS Brand: Router Brand: Switch Brand:

10. Is there an available UPS in the networking room that can be used for telemedicine? Yes No

10a. If yes, are there two available outlets on the unit that can be dedicated for telemedicine use?

Yes

No

10b. If you answered “no” to question 10 above, is there one available outlet in the networking room available for telemedicine use? (for a UPS to be brought in)

Yes

No

10c. If you answered “yes” to question 10 above, are any of these outlets on a dedicated circuit?

Yes

No

APPENDIX B:
Summary of Questionnaire Results
Site Assessment Questionnaire Site Readiness Questionnaire San Joaquin Valley Ranking Results

APPENDIX A1. QUESTIONNAIRE AND RESULTS

Valley Telehealth Partnership Questionnaire
1. Are you a “Key Decision Maker” at this facility? 94 % 6% 2. Yes No 9. 8. What is your clinic/facility’s daily visit average? 81 97 Average daily visits for all clinics Average daily visits for all hospitals

Is your location considered rural or urban? 89% 11% Rural Urban

What is your clinic/facility’s annual visit average? 20,652 Average annual visits for all clinics 47,787 Average annual visits for all hospitals

3.

Are you a recognized FQHC facility? 10. How many PCPs practice in your facility? 66% 34% Yes No 7 9 Average number of PCPs in clinics Average number of PCPs in hospitals

4.

Please circle the best description/s of your facility below: 77% 21% 2% Outpatient Clinic Hospital Behavioral Health Clinic

11. How many PAs practice in your facility? 4 2 Average number of PAs in clinics Average number of PAs in hospitals

5.

Please circle the best description of your provider type below: 68% 22% 4% 4% 2% 0% Community Health Clinic Rural Health Clinic Non-Profit Hospital Other For-Profit Hospital Mental Health Clinic

12. What is the estimated payor mix of your current patient base?
County Merced Mariposa Fresno San Joaquin Calaveras Kern Kings Tulare Stanislaus Cash Medi-Cal 8.6 69.2 21.3 34.2 8.5 58.2 0 48 3 15 20.2 55.3 20 50 9.3 53.5 25 60 Other 3 0.3 6.2 25 5 11.2 8.5 3.3 0 Priv. Insur. MediCare 8.6 10 19.5 39.8 6.5 15.3 9 18 28 50 5.6 6.6 12 8.5 22.8 6.9 5 10

6.

Are you interested in using telemedicine at your facility? 94% 6% Yes No

13. Which five specialty referrals are most commonly needed by patients seen in your facility? (Please number 1-5 in order of perceived need; 1= highest need) 1 2 3 4 5 Dermatology Cardiology Pediatric Psychiatry Gastroenterology

7.

If yes, which uses are you most interested in? 93% 2% 2% 2% 2% 2% 2% Outpatient Specialty Consults Distance Continuing Ed E/R Consults Tele-Radiology Tele-Ultrasound Tele-Fetal Monitoring Patient Monitoring (Real Time)

14. Is gaining access to medical specialists a problem for your patients? 90% 10% Yes No

17. How often do you estimate these patients return for the necessary follow up care? (i.e. 17% of facilities in Fresno County report that less than 10% of patients return for follow-up care.)
County % Facilities % Follow-up
26-50% 17% 8% 25% 42% 8% 14% 50% 22% 14% Less than 10% 11-25% 26-50% 51-75% 76-100% 11-25% 26-50% 51-75% 76-100% 51-75% 51-75% 26-50% 26-50% 26-50% 25% 25% 25% 25% Less than 10% 11-25% 26-50% 51-75% Calveras Fresno

15. How many out-of-town referrals to medical specialists are you making per month? By County Calaveras Fresno Kern Kings Madera Mariposa Merced San Joaquin Stanislaus Tulare

21 22 5 13 7 138 42 5 1 24

Kern

Kings Madera Merced San Joaqin Stanislaus Tulare

16. How often do you estimate your patients are able to follow through with referrals to out-oftown specialists? (i.e. 31% of facilities in Fresno County report that patients follow through 11-25% of the time.)
County Calveras
Fresno

% Facilities

% Follow-thru 51-75%
11-25% 26-50% 51-75% 76-100% Less than 10% 11-25% 26-50% 51-75% 76-100% 11-25% 11-25% Less than 10%

31% 23% 23% 23% 14% 50% 8% 14% 14%

Kern

18. Telemedicine technology enables primary care physicians in rural or underserved communities to connect their patients with out-of-area specialists in real time consults, or via store and forward capabilities, allowing for convenient, local access to specialty healthcare. In your opinion, is this something your patients and facility would benefit from using? 87% 13% Yes No

Kings Madera Mariposa Merced 60% 20% 20%

19. Based on the current needs of your facility, what would you estimate your monthly use of telemedicine to be (# of consults)? 30 45 Average # of consults for clinics Average # of consults for hospitals

11-25% 26-50% Less than 10% 51-75% 51-75%

San Joaquin Stanislaus Tulare 25% 75%

11-25% 51-75%

20. Would live access to interactive continuing medical education (such as patient rounds) for your physicians and medical staff be of value to you? 89% 11% Yes No

26. Is your clinic/facility able to commit some of its financial resources to the continuing operating costs required to sustain a telemedicine program? 84% 16% Yes No

21. How often would you or your staff be interested in accessing educational benefits? 43% 22% 27% 5% 1% Weekly Biweekly Monthly Quarterly Annually

27. Please specify the level of financial commitment you anticipate being able to provide per month: (costs may include: connectivity, video conferencing time & some staffing time) 28% 51% 4% 15% 2% None $200-500 $600-1200 $1300-2500 $2600 and up

22. Do you think that the physicians at your facility would be interested in using telemedicine? 91% 2% 7% Yes No Not sure

28. Is your clinic/facility willing to provide UC Merced with non-confidential (no patient identifying data) utilization reports on an ongoing (monthly) basis? 74% 26% Yes No

23. If telemedicine were provided by your facility, would you be interested in educating your community about the benefits of telemedicine? 83% 17% Yes No

29. Is your clinic/facility willing to remain in regular contact with UC Merced’s Telemedicine Project Manager in order to ensure program success? 79% 21% Yes Does Not Apply

24. Are you willing to provide periodic telemedicine demonstrations to patients in order to raise awareness and increase utilization of telemedicine services? 79% 21% Yes No

30. Do you currently have an internet connection at your clinic/facility? 96% 4% Yes No

25. Is your clinic/facility willing to commit some staff time to the training required to use telemedicine successfully? 90% 10% Yes No

31. If yes, how do you connect? (circle one): 48% 31% 21% T1 DSL Cable

32. Do you currently operate on a wireless network? 64% 36% No Yes

UC Merced Valley Telehealth Partnership Site Readiness Questionnaire Summary of Results (Collected 2008)
Section 1: Telemedicine Physical Room Accommodation
Please answer the following questions to the best of your ability for each room that you feel could be considered for the use of telemedicine. If you have only one room to consider, please skip to section 2 below after completing your information for the first room.

N = 54 (49 sites with 3 sites reporting 2 rooms, and 1 site reporting 3 rooms)
01. Do you have a 10 x 10 or larger room that maybe designated for telemedicine 30% or more of the time? 1a. If so, please note the room’s measurements: 02. Approximately how often would you expect this room to be available for the purpose of telemedicine consults? 100% 0% 100% Yes No 10’ x 10’ or greater

8 (15%) <50% 26 (49%) =50% 19 (36%) >50% (7=100%) ------------------------1 (2%) no answer 27 (50%) 11 (20%) 7 (13%) 5 (9%) 3 (6%) 1 (2%) 35% 65% Patient Consult Emergency Room Procedures Room Exam Room Not in use Admin/office Yes No

03.

How is this room currently used?

04.

Is this room located next to any busy areas with lots of noise? What types of rooms are located next to this room?

05.

25 (46%) Patient Consult Room 13 (24%) Consult Room & Nurses’ Station 10 (19%) Other Exam Rooms 2 (4%) Lab 1 (2%) Dental Operatories 1 (2%) Medical Records 1 (2%) Sterilize Room 1 (2%) Triage

06.

The following will require that you go into the room, close the door, and evaluate the following: 6a. Quietly listen for noise for 30 seconds and check off any of the following sounds that you hear:

(multiple responses) 40 (74%) Noise…
25 (46%) 18 (33%) 17 (31%) 15 (28%) Voices Air/Heat Fluorescent Lights Outside

14 (26%) No Noise 6b. Now clap your hands several times, do you hear an echo in the room? 07. 08. Is this room conveniently located for physicians to use regularly throughout the day (within 5 minute walk or less)? Does the room have windows? 8a. If so, are there window coverings? 09. Does the room have patterns on the wall (i.e. wall paper)? 9a. What color are the walls? 72% 28% 98% 2% 46% 54% Yes No Yes No Yes No Yes No Yes No

24 (96%) 1 (4%) 2 (4%) 52 (96%)

8 (15%) White 34 (64%) Off-White/ Beige/ Grey/ Egg Shell 9 (17%) Swiss Coffee 2 (4%) Light Blue or Green ------------------------1 (2%) no answer 48 (89%) 6 (11%) Yes No

9b. Is the paint in good condition? 10. What type of flooring is in this room?

11.

Light sources (check type of light and note how many of each are located in the room).

3 (6%) Carpet 1 (2%) Cement 0 -- Hardwood 45 (83%) Linoleum 5 (9%) Other (multiple responses) 49 (91%) Overhead fluorescents 1 (2%) Desk lamp 0 -Standing torch light 14 (26%) Gooseneck 2 (4%) Other ------------------------3 (6%) no answer 16 (30%) 1 (2%) 34 (63%) 3 (5%) Two Three Four >Five

12.

How many electrical outlets are in the room?

13.

Is there a phone jack/line available? 13a. Can it be used for telemedicine purposes (incoming/outgoing calls)?

35 (65%) 19 (35%)

Yes No

Of those that answered “Yes” in Question 13 above: 35 (100%) Yes (0%) No Of those that answered “No” in Question 13 above: 8 (42%) Yes 11 (58%) No 32 (59%) Yes 22 (41%) No 16 (50%) One 12 (38%) Two 4 (12%) Four ------------------------22 (41%) None 38 (70%) Yes 16 (30%) No (multiple responses) 35 (92%) 31 (82%) 28 (74%) 0 -0 -Counter Sink Cabinet Table Other

13b. If not, can another phone line be brought in?

14.

Are there any computer (networking) jacks located in the room? 14a. How many?

15.

Are there any permanent furnishings (sinks, counters, cabinets, tables, etc.) located in the room? 15a. If yes, please specify and note the measurements of each:

Section 2: Telemedicine Network Accommodation
Please complete the following section regarding your facility’s network. Note that it may be helpful to have a member of your IT staff complete this portion of your survey. 01. Where is your network equipment located? 1a. Is the air ventilated? 1b. Is the space air conditioned? 02. Who is your internet provider? 25 (46%) Closet 29 (54%) Room 52 (96%) Yes 2 (4%) No 35 (65%) Yes 19 (35%) No Arrival AT&T Charter Communication Comcast SBC Self-Managed Service (AT&T) Time Warner Valley Technology Verizon 54 (96%) Yes 2 (4%) No 30 10 7 5 1 1 0 (56%) (19%) (13%) (9%) (2%) (2%) --T1 Line 10 med DSE3 DSL/Cable Fiber HDSL 4 mbps Satellite Dial-up

03. Do you have an IT staff/team that is easily able to assist with troubleshooting/maintenance of your current network and equipment? 04. What kind of internet connection is being used?

4a. Please specify how much bandwidth is currently being used: 05. If a T1 line must be brought into the building for Telemedicine use, where is its preferred placement?

Between <1.3mb to 3-5 mbps to T1 (multiple responses) 39 (89%) Rack 8 (18%) Wall 1 (2%) No space ------------------------10 (19%) no answer 27 (51%) Yes 26 (49%) No ------------------------1 (2%) no answer 47 (87%) Yes 7 (13%) No 54 (100%) Yes 0 -No

06. Is there enough copper available (a minimum of two pairs of copper is needed) for a T1 line to be brought in for the use of telemedicine? 6a. Is there enough room for networking equipment (approximately 5 square feet)? 07. Is there enough space in the networking room for a new router?

08. Is there enough space in the networking room for a new UPS? 09. Does the site have any preference on brands for the new networking equipment? 09a. If yes, please specify the brand preference with the corresponding type of equipment in the blanks provided

54 (100%) Yes 0 -No 49 (91%) Yes 5 (9%) No UPS Brand: APC (100%)

Router Brand: Cisco (92%) Sonic Wall (4%) Speed Street (4%) Switch Brand: Cisco (92%)
Dell Power Connect

(4%)

Netgear (4%) 10. Is there an available UPS in the networking room that can be used for telemedicine? 10a. If yes, are there two available outlets on the unit that can be dedicated for telemedicine use? 10b. If you answered “no” to question 10 above, is there one available outlet in the networking room available for telemedicine use? (for a UPS to be brought in) 10c. If you answered “yes” to question 10 above, are any of these outlets on a dedicated circuit? 30 (56%) Yes 24 (44%) No 17 (57%) Yes 13 (43%) No 10 (42%) Yes 14 (58%) No

14 (47%) Yes 16 (53%) No

San Joaquin Valley’s Ranking Results, page 1 Rank Clinic Code # Location – County Final Total Score
(out of 100 points) Mean = 29.7

Transitional Score
(without disqualifiers) Mean = 79.4

Missing Key Component(s)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38

16 37 36 12 23 15 14 21 24 9 17 6 8 4 5 22 7 11 28 1B 1A 20 19 13 18 38 33 3A 26B 43 29 34 30 26A 47 31 2A 41

Fresno Kern Kern Fresno Kern Fresno Fresno Kern Kern Kern Fresno Kern Kern Kern Kern Kern Kern Kern Kern Kings Kings Kern Kern Fresno Kern Kern Kern Tulare Stanislaus Tulare Kern Kern Kern Stanislaus Tulare Kern Mariposa Tulare

70.0 68.0 65.6 65.2 64.4 62.6 59.4 59.4 59.4 59.4 59.2 59.0 59.0 59.0 58.9 58.1 57.2 57.2 57.2 56.9 56.9 56.9 56.9 56.6 55.6 51.8 51.8 0 0 0 0 0 0 0 0 0 0 0

84.5 85.7 80.7 82.2 79.3 79.6 79.4 79.4 79.4 79.4 78.3 78.5 78.2 77.9 77.2 78.4 78.7 78.4 78.4 77.8 77.8 77.8 77.8 75.1 76.2 66.9 66.9 91.2 89.3 86.3 85.4 84.0 83.1 82.6 82.6 81.6 81.5 81.3

---------------------------space space funding space space space space funding space space funding

San Joaquin Valley’s Ranking Results, page 2 Rank Clinic Code # Location – County Final Total Score
(out of 100 points) Mean = 29.7

Transitional Score
(without disqualifiers) Mean = 79.4

Missing Key Component(s)

39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

25 49 40 42 35 10 32 39 2B 48 46 44 3B 3C 27 45

Merced Fresno Tulare Tulare Kern Kern Kern Tulare Mariposa Tulare Tulare Tulare Fresno Fresno Merced Tulare

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

81.0 81.0 80.9 80.1 80.1 79.7 79.5 78.9 78.8 78.4 78.0 77.2 77.1 75.2 73.6 69.0

space funding funding funding space space space funding space funding funding funding space space funding & space funding

APPENDIX C:
Questionnaire Score Cards for Ranking
Site Assessment Room Accommodations Network Accommodations

#

VTP Telemedicine Site Assessment Questionnaire Score Card (Survey #1) Code for Question Weighting Point Allocation
1 Are you a “Key Decision Maker” at this facility? 2 Is your location considered rural or urban? 3 Are you a recognized FQHC facility? Interest Access Funding Access Access Interest Access Volume Volume Volume Volume

Please circle the best description/s of your facility 4 below:

Yes = 5 points Rural = 5 points Yes = 5 points n/a n/a Yes = 0 points Yes = Up to 5 points (1per use) ≥20 = 5 points
n/a

No = 0 points Urban = 0 points No = 0 points

Please circle the best description of your provider
5 type below:

Are you interested in using telemedicine at your
6 facility? 7 If yes, which uses are you most interested in? 8 What is your clinic/facility’s daily visit average? 9 What is your clinic/facility’s annual visit average? 10 How many PCPs practice in your facility? 11 How many PAs practice in your facility?

No = DQ None = 0 points Less than 20 = 0 points

More than 3 = 5 points 3 or less = 0 points One or more = 5 points 0 = 0 points >20 Cash; >20 Private ins.; <20 Medical; <30 Medicare; Reimbursements <20 Other; = 2 points each if What is the estimated payor mix of your current patient value met 12 base?
Which five specialty referrals are most commonly
13 needed by patients seen in your facility? Referrals Specialty Access Referrals Any Answer = 7 points

Is gaining access to medical specialists a problem for 14 your patients? How many out of town referrals to medical specialists 15 are you making per month? How often do you estimate your patients are able to 16 follow through with referrals to out of town specialists? How often do you estimate these patients return for the 17 necessary follow up care? Telemedicine technology enables primary care physicians in rural or underserved communities to connect their patients with out-of-area specialists in real time consults, or via store and forward capabilities, allowing for convenient, local access to specialty healthcare. In your opinion, is this something your 18 patients and facility would benefit from using? Based on the current needs of your facility, what would you estimate your monthly use of telemedicine to be (# 19 of consults)? Would live access to interactive continuing medical education (such as patient rounds) for your physicians 20 and medical staff be of value to you?

Yes = 5 points Over 25 = 5 points Less than 10%, 11-25%, 2650% = 5 points Less than 10%, 11-25%, 2650% = 5 points Yes = 0 points

No = 0 points 10-25 = 2.5 points Under 10 = 0 points 51-75%, 76-100% = 0 points

Access

Access

51-75%, 76-100% = 0 points No = DQ

Interest

25+ = 5 points
Volume

10-25 = 2.5 points; Under 10 = 0 points No = 0 points

Yes = 5 points
Equipment

How often would you or your staff be interested in
21 accessing educational benefits?

Equipment Interest

≥ 1 x month = 5 points Yes = 5 points Yes = 5 points

Less than 1 x month = 0 points Not sure = 0 points; No = DQ No = 0 points

Do you think that the physicians at your facility would
22 be interested in using telemedicine?

If telemedicine were provided by your facility, would you be interested in educating your community about 23 the benefits of telemedicine? Are you willing to providing periodic telemedicine demonstrations to patients in order to raise awareness 24 and increase utilization of telemedicine services?

Interest

Yes = 5 points
Interest

No = 0 points

Is your clinic/facility willing to commit some staff time to the training required to use telemedicine 25 successfully? Is your clinic/facility able to commit some of its financial resources to the continuing operating costs 26 required to sustain a telemedicine program? Please specify the level of financial commitment you anticipate being able to provide per month: (costs may include: connectivity, video conferencing time & some 27 staffing time) Is your clinic/facility willing to provide UC Merced with non-confidential (no patient identifying data) 28 utilization reports on an ongoing (monthly) basis? Is your clinic/facility willing to remain in regular contact with UC Merced’s Telemedicine Project 29 Manager in order to ensure program success? Do you currently have an internet connection at your 30 clinic/facility?
31 If yes, how do you connect? (circle one): 32 Do you currently operate on a wireless network?

Yes = 0 points
Funding

No = DQ

Yes= 0 points
Funding

No=DQ

Funding

$1300-2500, 2600 and up = 5 None=0 points points $200-500, 600-1200 = 2.5 points Yes=0 points No= DQ

Interest

Yes = 0 points
Interest

No = DQ

Technology Technology Technology

Yes = 2.6 points T1 = 2.5 points Yes = 2 points

No = 0 points Modem/ Dial up, DSL, Cable = 0 points No = 0 points

#

VTP Site Readiness Questionnaire Score Card (Survey #2A: Room Accommodations) Code for Question Weighting Point Allocation
1 Do you have a 10 x 10 or larger room that maybe designated
for telemedicine 30% or more of the time? 1a. If so, please note the room’s measurements:
Space Space

If no, automatic 0 score

If yes, automatic 0 score

2 Approximately how often would you expect this room to be
available for the purpose of telemedicine consults?

Above 10 x 10 or Below 20 Larger than 20 x 20= 2.5 x 20= 5 points points 50% + of the time= 5 points 30-50%= 2.5 points

Volume Patients Consultation/Not in Administration office/Break use rooms= 5 points room= 2.50 points; Triage, emergency, or surgery rooms= 0 points = Automatic Disqualifiers If yes, automatic disqualifier No= 0 points Lab, patient consultation, or Waiting room, break room, or storage = 5 points cafeteria= 2.5 points; Triage room= 0 points More than 2 noises= 2.5 points Yes= 0 points No= 0 points

3 How is this room currently used?
Space

4 Is this room located next to any busy areas with lots of noise? 5 What types of rooms are located next to this room?

Space

Space

6 The following will require that you go into the room, close the door, and evaluate the following: 6a. Quietly listen for noise for 30 seconds and check off any of None=5 points Space the following sounds that you hear: 1 Noise=4 points 6b. Now clap your hands several times, do you hear an echo No= 5 points Space
in the room? Is this room conveniently located for physicians to use regularly throughout the day (within 5 minute walk or less)?

Yes= 5 points
Space Space

7 8 Does the room have windows?

8a. If so, are there window coverings? Does the room have patterns on the wall (i.e. wall paper)?
9

Funding Funding Funding Funding Funding

Yes= 0 points Yes=5 points No= 5 points

No= 0 points No= 0 points Yes= 0 points

9a. What color are the walls? 9b. Is the paint in good condition? What type of flooring is in this room?
10

Neutral or light colors=5 Dark colors=0 points points Yes=5 points No=0 points Hardware, Carpet, Cement= 0 points Linoleum, or other= 5 points Overhead fluorescent= 5 points 1 = 2.5 points 2 or more= 5 points Yes= 5 points Yes= 5 points N/A Yes= 5 points Desk lamp, standing torch light, gooseneck, other= 0 points 0 outlets= 0 points No= 0 points No= 0 points If “no” disqualify No= 0 points

Light sources (check type of light and note how many of each are located in the room).
11

Space Space Space Space Space Funding Funding Space

How many electrical outlets are in the room?
12 13 Is there a phone jack/line available?

13a. Can it be used for telemedicine purposes (incoming/outgoing calls)? 13b. If not, can another phone line be brought in? Are there any computer (networking) jacks located in the 14 room? 14a. How many? Are there any permanent furnishings (sinks, counters, cabinets, tables, etc.) located in the room?
15

15a. If yes, please specify and note the measurements of each:

Space

1= 2.5 points 2 or more= 5 points Yes, 12 x 12 or larger= 2.5 No, add all points. points; Yes, 10 X 12 or less= 0 points 1 furnishing=3 points Marked appropriate 2 or more furnishings= 2.5 furnishings but no points measurements = 0 points

VTP Site Readiness Questionnaire Score Card (Survey #2B: Network Accommodations) Code for Weighting
Technology

#

Question
1 Where is your network equipment located?

Point Allocation
No= 0 points No= 0 points No=0 points

1a. Is the air ventilated? 1b. Is the space air conditioned? 2 Who is your internet provider? Do you have an IT staff/team that is easily able to assist with troubleshooting/maintenance of your current network and 3 equipment? What kind of internet connection is being used?
4

Answer has no weight Yes= 8.3 points Space Yes= 8.3 points Space Technology Answer has no weight Yes= 8.3 points
Technology Technology

4a. Please specify how much bandwidth is currently being used:
Funding

T1 or Fiber= 8.3 points DSL/Cable or Dialup= 0 points Answer has no weight

If a T1 line must be brought into the building for Telemedicine Answer has no weight 5 use, where is its preferred placement? Space Is there enough copper available (a minimum of two pairs of Yes= 8.3 points copper is needed) for a T1 line to be brought in for the use of 6 telemedicine? Technology 6a. Is there enough room for networking equipment Yes= 8.3 points (approximately 5 square feet)? Space Is there enough space in the networking room for a new router? Yes= 8.3 points
7 Space

No= 0 points

No=0 points No= 0 points No= 0 points

Is there enough space in the networking room for a new UPS?
8 Space

Yes= 8.3 points Answer has no weight
Technology

Does the site have any preference on brands for the new
9 networking equipment?

09a. If yes, please specify the brand preference with the corresponding type of equipment in the blanks provided
Technology

Answer has no weight

Is there an available UPS in the networking room that can be 10 used for telemedicine? 10a. If yes, are there two available outlets on the unit that can be dedicated for telemedicine use? 10b. If you answered "no" to question 10 above, is there one available outlet in the networking room available for telemedicine use? (for a UPS to be brought in) 10c. If you answered "yes" to question 10 above, are any of these outlets on a dedicated circuit?

Yes= 8.3 points
Space

No= 0 points No= 0 points

Yes= 8.3 points
Space

Yes= 4.1 points; Yes on No= 0 points 10a &10b=Only give No to 10a and 10b= 0 full point on 10. points
Space

Yes= 8.3 points
Space

No= 0 points