Telemedicine: Federal Strategy Is Needed to Guide Investments (Chapter
Report, 02/14/97, GAO/NSIAD/HEHS-97-67).

Pursuant to a congressional request, GAO reviewed the steps that the
federal government needs to take to realize the full potential of
telemedicine and achieve cooperation with the private sector, focusing
on: (1) the scope of public and private telemedicine investments; (2)
telemedicine strategies among the Department of Defense (DOD), other
federal agencies, and the private sector; (3) potential benefits that
the public and private sectors may yield from telemedicine initiatives;
and (4) barriers facing telemedicine implementation.

GAO found that: (1) collectively, the public and private sectors have
funded hundreds of telemedicine projects that could improve, and perhaps
change significantly, how health care is provided in the future; (2)
however, the amount of the total investment is unknown; (3) 9 federal
departments and independent agencies invested at least $646 million in
telemedicine projects from fiscal years 1994 to 1996; (4) DOD is the
largest federal investor with $262 million and considered a leader in
developing this technology; (5) state-supported telemedicine initiatives
are growing; (6) estimates of private sector involvement are impossible
to quantify because most cost data is proprietary and difficult to
separate from health care delivery costs; (7) opportunities exist for
federal agencies to share lessons learned and exchange technology, but
no governmentwide strategy exists to ensure that the maximum benefits
are gained from the numerous federal telemedicine efforts; (8) the Joint
Working Group on Telemedicine (JWGT) is the first mechanism structured
to help coordinate federal programs; (9) however, its efforts to develop
a federal inventory, a critical starting point for coordination, have
been hampered by definitional issues and inconsistent data; (10) in
addition, DOD and other federal departments do not have strategic plans
to help guide their telemedicine investments, assess benefits, and
foster partnerships; (11) telemedicine is an area in which public and
private benefits converge; (12) many anecdotal examples demonstrate how
telemedicine could improve access and quality to medical care and reduce
health care costs; (13) however, comprehensive, scientific evaluations
have not been completed to demonstrate the cost benefits of
telemedicine; (14) the expansion of telemedicine is hampered by legal
and regulatory, financial, technical, and cultural barriers facing
health care providers; (15) some barriers are too broad and have
implications too far-reaching for any single sector to address; (16)
telemedicine technology today is not only better than it was decades
ago, it is becoming cheaper; (17) consequently, the questions facing
telemedicine today involve not so much whether it can be done but rather
where investments should be made and who should make them; (18) the
solution lies in the public and private sectors' ability to jointly
devise a means to share information and overcome barriers; and (19) the*

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  NSIAD/HEHS-97-67
     TITLE:  Telemedicine: Federal Strategy Is Needed to Guide 
             Investments
      DATE:  02/14/97
   SUBJECT:  Health care services
             Telecommunication
             Medical records
             Health care cost control
             Medical information systems
             Health services administration
             Patient care services
             Strategic information systems planning
             Interagency relations
IDENTIFIER:  Medicare Program
             Georgia
             Texas
             North Carolina
             DOD TRICARE Program
             Medicaid Program
             National Information Infrastructure Program
             USDA Distance Learning and Medical Link Grant Program
             Theater Army Medical Management Information System
             DOD Military Health Services System
             Army Medical Diagnostic Imaging Support System
             
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Cover
================================================================ COVER


Report to Congressional Requesters

February 1997

TELEMEDICINE - FEDERAL STRATEGY IS
NEEDED TO GUIDE INVESTMENTS

GAO/NSIAD/HEHS-97-67

GAO/NSIAD-97-67

Telemedicine

(703120)


Abbreviations
=============================================================== ABBREV

  AT&T - American Telephone and Telegraph
  BOP - Bureau of Prisons
  DARPA - Defense Advanced Research Projects Agency
  DOD - Department of Defense
  FDA - Food and Drug Administration
  FTCA - Federal Tort Claims Act
  GAO - General Accounting Office
  HCFA - Health Care Financing Administration
  HHS - Department of Health and Human Services
  IHS - Indian Health Service
  JWGT - Joint Working Group on Telemedicine
  MATMO - Medical Advanced Technology Management Office
  MDIS - Medical Diagnostic Imaging Support
  MHSS - Military Health Services System
  NASA - National Aeronautics and Space Administration
  ORHP - Office of Rural Health Policy
  VA - Department of Veterans Affairs

Letter
=============================================================== LETTER


B-272523

February 14, 1997

The Honorable Curt Weldon
Chairman
The Honorable Owen B.  Pickett
Ranking Minority Member
Subcommittee on Military Research
 and Development
Committee on National Security
House of Representatives

The Honorable John M.  Spratt, Jr.
House of Representatives

This report responds to your request for information about the steps
that the federal government needs to take to realize the full
potential of telemedicine and achieve cooperation with the private
sector.  Specifically, we address the (1) scope of public and private
telemedicine investments; (2) telemedicine strategies among the
Department of Defense, other federal agencies, and the private
sector; (3) potential benefits that the public and private sectors
may yield from telemedicine initiatives; and (4) barriers facing
telemedicine implementation.  Our recommendations are designed to
help move federal departments and agencies toward the goals and
objectives as stated in the Government Performance and Results Act of
1993. 

We are sending copies of this report to the Office of the Vice
President; the Secretaries of Defense, Veterans Affairs, Health and
Human Services, the Army, the Navy, and the Air Force; the Director,
Office of Management and Budget; appropriate congressional
committees; and other interested parties.  We will provide a copy of
this report to the new Ranking Minority Member when named.  We will
also make copies available to others on request. 

This report was prepared under the direction of Mark E.  Gebicke,
Director, Military Operations and Capabilities Issues, who may be
reached at (202) 512-5140 if you or your staff have any questions
concerning this report.  Other major contributors to this report are
listed in
appendix VI. 

Henry L.  Hinton, Jr.
Assistant Comptroller General


EXECUTIVE SUMMARY
============================================================ Chapter 0


   PURPOSE
---------------------------------------------------------- Chapter 0:1

During a deployment in the Western Pacific region, a sailor aboard
the U.S.S.  Abraham Lincoln became seriously injured and was seen and
treated by a specialist in San Diego--6,000 miles away.  Doctor and
patient were linked by telemedicine, which, in its broadest sense,
refers to the use of communications technology to help deliver
medical care without regard to the distance that separates the
participants.  In addition to the Department of Defense (DOD), other
federal agencies, state governments, and private organizations
support telemedicine initiatives. 

Congress has raised questions about the federal government's role in
advancing telemedicine.  In this regard, the Chairman and Ranking
Minority Member, Subcommittee on Research and Development, House
Committee on National Security, asked GAO to help determine the steps
that DOD and the federal government need to take to realize the full
potential of telemedicine and achieve cooperation with the private
sector.  Specifically, this report addresses the (1) scope of public
and private telemedicine investments; (2) telemedicine strategies
among DOD, other federal agencies, and the private sector; (3)
potential benefits that the public and private sectors may gain from
telemedicine initiatives; and (4) barriers facing telemedicine
implementation. 


   BACKGROUND
---------------------------------------------------------- Chapter 0:2

Depending on how it is defined, telemedicine can involve the use of
imaging and diagnostic equipment to gather data from a patient,
computer hardware and software to record data, communication lines or
satellites to send the data from one location to another, and
computer equipment at the receiving end for a physician or specialist
to interpret the data.  A telemedicine system could be as simple as a
computer hookup to a medical reference source or as advanced as
robotic surgery.  A comprehensive system would integrate various
applications--clinical health care delivery, management of medical
information, education, and administrative services--within a common
infrastructure.  This infrastructure includes the physical facilities
and equipment used to capture, transmit, store, process, and display
voice, data, and images. 

Telemedicine has existed in some form for almost 40 years.  Early
expansion was confined, however, by the cost and limitations of the
technology.  Recent technological advances, such as fiber optics,
satellite communications, and compressed video, have eliminated or
minimized many of these problems, fostering a resurgence of private
and public sector interest in telemedicine. 

GAO's review focused primarily on DOD to meet the needs of the House
Subcommittee on Research and Development.  To provide a broader
perspective, the review also encompassed work at numerous other
federal agencies, state governments, and private organizations that
support telemedicine initiatives.  GAO's overall approach was
twofold.  First, GAO conducted a broad data collection and analysis
effort at numerous organizations.  Second, GAO performed a
cross-cutting case study of public and private telemedicine projects
in one state.  Georgia was chosen because it had state, academic, and
private sector funding for telemedicine efforts as well as
collaboration with DOD on telemedicine projects.  GAO also reviewed
relevant literature to supplement its analysis. 


   RESULTS IN BRIEF
---------------------------------------------------------- Chapter 0:3

Collectively, the public and private sectors have funded hundreds of
telemedicine projects that could improve, and perhaps change
significantly, how health care is provided in the future.  However,
the amount of the total investment is unknown.  GAO identified nine
federal departments and independent agencies that invested at least
$646 million in telemedicine projects from fiscal years 1994 to 1996. 
DOD is the largest federal investor with $262 million and considered
a leader in developing this technology.  State-supported telemedicine
initiatives are growing.  Estimates of private sector involvement are
impossible to quantify because most cost data is proprietary and
difficult to separate from health care delivery costs. 

Opportunities exist for federal agencies to share lessons learned and
exchange technology, but no governmentwide strategy exists to ensure
that the maximum benefits are gained from the numerous federal
telemedicine efforts.  The Joint Working Group on Telemedicine
(JWGT), created in 1995 under the Vice President's charge to the
Secretary of Health and Human Services (HHS) to report on
telemedicine issues, is the first mechanism structured to help
coordinate federal programs.  However, its efforts to develop a
federal inventory--a critical starting point for coordination--have
been hampered by definitional issues and inconsistent data.  In
addition, DOD and other federal departments do not have strategic
plans to help guide their telemedicine investments, assess benefits,
and foster partnerships.  Some federal officials are beginning to
recognize the need to develop such strategies. 

Telemedicine is an area in which public and private benefits
converge.  Many anecdotal examples demonstrate how telemedicine could
improve access and quality to medical care and reduce health care
costs.  However, comprehensive, scientific evaluations have not been
completed to demonstrate the cost benefits of telemedicine.  The
expansion of telemedicine is hampered by legal and regulatory,
financial, technical, and cultural barriers facing health care
providers.  Some barriers, such as multiple state licenses, privacy,
and infrastructure costs, are too broad and have implications too
far-reaching for any single sector to address. 

Telemedicine technology today is not only better than it was decades
ago; it is becoming cheaper.  Consequently, the questions facing
telemedicine today involve not so much whether it can be done but
rather where investments should be made and who should make them. 
The solution lies in the public and private sectors' ability to
jointly devise a means to share information and overcome barriers. 
The goal is to ensure that an affordable telecommunications
infrastructure, with interoperable software and hardware, is in place
and that the true merits and cost benefits of telemedicine are
attained in the most appropriate manner. 


   PRINCIPAL FINDINGS
---------------------------------------------------------- Chapter 0:4


      INVESTMENTS ARE SIGNIFICANT,
      BUT TOTAL IS UNKNOWN
-------------------------------------------------------- Chapter 0:4.1

Over 35 federal organizations within 9 federal departments or
independent agencies, 10 state governments, and numerous private
sector organizations sponsor hundreds of telemedicine initiatives in
over 40 states.  The total investment is unknown because telemedicine
costs are often embedded within health care delivery costs and
private sector data is proprietary.  Of the $646 million that federal
agencies invested in telemedicine from fiscal years 1994 to 1996, DOD
invested the most--$262 million--followed by the Departments of
Veterans Affairs (VA), HHS, and Commerce, each investing over $100
million. 

Nearly $105 million, or 40 percent, of DOD's investment is devoted to
unique long-term research and development projects for battlefield
applications that the Defense Advanced Research Projects Agency
(DARPA) has sponsored.  The rest of DOD's investment primarily
supports peacetime applications at its medical treatment facilities,
particularly to improve information management such as digitized
radiology or computerized patient tracking systems.  Similarly, the
other eight federal departments and independent agencies devoted 57
percent of their combined $384 million investment for information
management.  A large portion of this investment also supported
clinical health care delivery and infrastructure development in rural
or remote areas. 

State telemedicine investments have been expanding health care in
rural or remote areas.  States with the longest track record, such as
Georgia, have taken legislative action to support telemedicine and
provide direct funding.  Georgia has also set a reduced rate across
the state for medical communications.  Although estimates of the
private sector investment in telemedicine have not been quantified,
the Koop Institute estimates that the U.S.  market was in the
billions of dollars for telecommunications infrastructure, computer
hardware and software, and biomedical equipment.  Many private
organizations also use telemedicine to help deliver health care. 


      NO FEDERAL STRATEGY EXISTS
      TO MAXIMIZE THE VALUE OF
      TELEMEDICINE INVESTMENTS
-------------------------------------------------------- Chapter 0:4.2

No formal mechanism or overall strategy exists to ensure that
telemedicine development is fully coordinated among federal agencies
to serve a common purpose.  Numerous federal, state, and private
sector groups are involved in telemedicine activities.  The federal
agencies involved are seeking solutions to more narrowly defined
problems that fall under their purview.  For example, DOD has been
instrumental in developing telemedicine technologies that could
deliver medical care to the battlefield or operations other than war. 
The National Aeronautics and Space Administration is interested in
telemedicine primarily to understand its application to medical care
in space.  Agencies within HHS are interested in ways to deliver
health care to a variety of populations, including those in rural or
remote locations. 

The technologies that the various agencies are employing or
developing for their own missions can be related.  For example,
federal projects are experimenting with teleradiology--radiologic
image transmission within and among health care organizations.  These
efforts do not necessarily indicate that unwanted duplications are
occurring, but they illustrate the potential for one agency to be
aware of and take advantage of relevant technologies being developed
by another agency. 

Although some interagency coordination occurs on an ad hoc or narrow
basis (e.g., through working groups, symposiums, technology
demonstrations, and joint programs), these efforts do not provide a
firm basis for technology exchange.  JWGT has tried to fill the
information gap and facilitate coordination among federal departments
or agencies.  Its efforts to develop a comprehensive inventory of
federally funded telemedicine projects have been hampered by several
factors, including the lack of a consistent definition and
incompatible agency data.  JWGT was charged to prepare a report on
federal telemedicine projects, the range of potential telemedicine
applications, and public and private actions to promote telemedicine
and remove existing barriers to its use.  In addition, the
Telecommunications Act of 1996 (P.L.  104-104) directed the Secretary
of Commerce, in consultation with the Secretary of HHS, to submit a
report to Congress concerning JWGT activities.\1 Even DOD does not
know the full scope of its telemedicine efforts partly because of the
lack of agreement over what constitutes telemedicine.  Also, DOD-wide
oversight is exacerbated because numerous diverse organizations
generate projects at low levels. 

Without a departmentwide strategy to guide investments, some DOD
programs, such as DARPA's unique long-term research and development
efforts, may be difficult to justify and therefore may be in
jeopardy.  Also, organizational structure and oversight
responsibilities are still evolving, and a comprehensive budget for
the telemedicine program has not been developed.  Except for DARPA,
DOD has developed only limited partnerships with the private sector. 
Moreover, DOD's experiences may be indicative of telemedicine
activities throughout the federal government.  Some federal agencies
are beginning to recognize the need to develop a telemedicine
strategic plan. 

Given the wide range of private sector sponsors of telemedicine
(manufacturers, utility companies, managed care organizations, and
professional medical groups), it is understandable that no single
private sector strategy exists for the advancement of this emerging
technology.  However, the private sector has acknowledged the need to
build public and private partnerships to facilitate telemedicine
development. 


--------------------
\1 The Secretaries of Commerce and HHS issued their final report to
Congress and the Vice President on January 31, 1997. 


      TELEMEDICINE BENEFITS ARE
      PROMISING BUT LARGELY
      UNQUANTIFIED
-------------------------------------------------------- Chapter 0:4.3

By eliminating distance as a factor in medical care, telemedicine has
the potential to address some of the access, quality, and cost
problems facing public and private health care providers.  DOD
believes it could reduce battlefield fatalities if a medic were to
consult with a more skilled specialist early in the treatment
process.  The Navy has begun using telemedicine to provide access to
medical care for the 100,000 to 150,000 personnel routinely deployed
at sea.  That access proved critical for one sailor who injured his
hand on a gun mount.  The injured sailor was transferred from another
ship to the U.S.S.  Abraham Lincoln with the gun mount part still
implanted in his hand.  X-rays and video of his injury were
transmitted to San Diego, where a specialist consulted with the
ship's surgeon to treat the injury.  The sailor returned to light
duty on his ship
3 days later.  Similarly, emergency medical technicians could treat
accident victims more quickly in peacetime by using telemedicine to
consult with a physician. 

Although a 1992 private sector study estimated that using video
conferencing for medical consultations and continuing medical
education could reduce health care costs by $200 million annually,
the true merits, limitations, and cost-effectiveness of telemedicine
have yet to be empirically quantified.  Many anecdotal examples exist
to show how telemedicine can save money.  For example, teleradiology
used on a deployed aircraft carrier eliminated the need for 30
evacuations and saved about $100,000 over a 4-month period.  Over a
2-year period, Texas saved about $495,000 in transportation costs by
using telemedicine to care for its prison inmates rather than
transfer them to another facility. 

Large infrastructure start-up costs, high operational costs, and
inappropriate utilization, however, could offset potential cost
savings.  Without sharing telecommunication systems with other users,
health care facilities may find that their costs per consultation are
prohibitively high.  In managed health care settings, for example,
many costs, including monthly network expenses and physician
salaries, are fixed, and potential users must determine if
telemedicine technology is economically feasible.  In fee-for-service
settings, in which physician salaries depend on the services
provided, third-party payers, such as Medicare, are concerned that
providers may use complex and costly telemedicine technologies when
less costly techniques may be sufficient.  Officials from HHS' Health
Care Financing Administration are concerned that Medicare
expenditures could increase significantly if telemedicine
consultations are reimbursed.  Although various reports have
estimated that Medicare expenditures would increase by billions of
dollars, Health Care Financing Administration officials could not
estimate the amount of the potential increase, preferring to wait
until they complete several cost evaluations currently underway. 

Literature notes, however, that past telemedicine projects throughout
the United States have not included an evaluation component.  The
limited evaluations that have been performed often did not have a
sufficient sample size.  Several comprehensive evaluations are
currently underway to address some of these issues, but the results
will not be known for several years. 


      BARRIERS CURRENTLY INHIBIT
      ADOPTION OF TELEMEDICINE
-------------------------------------------------------- Chapter 0:4.4

Most experts agree that the major barriers to implementing
telemedicine are known but that the solutions are complex and require
cooperative efforts by all sectors involved in health care.  Legal
and regulatory barriers, such as physician licensure and malpractice
liability, impede private sector organizations more than they do
government providers.  Financial barriers, such as reimbursement for
certain medical procedures, affect the private sector, whereas the
lack of an affordable telecommunications infrastructure impedes all
sectors.  Some technical barriers, such as interoperability and
design standards, may persist even after an infrastructure is
established.  Physician and patient resistance may pose cultural
obstacles. 

Partnership efforts are already underway by policymakers and various
groups in the public and private sectors to develop strategies and
options for overcoming many of the barriers to telemedicine
applications.  Some groups believe that federal initiatives are
needed to resolve more complex legal issues, such as licensure for an
interstate practice of telemedicine. 


   RECOMMENDATIONS
---------------------------------------------------------- Chapter 0:5

Although there is a need to develop national goals and objectives to
guide federal telemedicine investments, it would be difficult for an
individual department or agency to be the architect of a
governmentwide strategy.  JWGT is already performing some interagency
coordination associated with carrying out the Vice President's charge
to the Secretary of HHS to prepare a comprehensive report on
telemedicine issues.  Therefore, JWGT is in a good position to expand
its work and take the lead in proposing a coordinated federal
approach for investing in telemedicine.  Such efforts should provide
a framework to optimize the value of federal telemedicine investments
with activities sponsored by the states and private sector. 

Accordingly, GAO recommends that the Vice President direct JWGT, in
consultation with the heads of federal departments and agencies that
sponsor telemedicine projects, to propose a federal strategy that
would establish near- and long-term national goals and objectives to
ensure the cost-effective development and use of telemedicine.  In
addition, the proposed strategy should include approaches and actions
needed to

  -- establish a means to formally exchange information or technology
     among the federal government, state organizations, and private
     sector;

  -- foster collaborative partnerships to take advantage of other
     investments;

  -- identify needed technologies that are not being developed by the
     public or private sector;

  -- promote interoperable system designs that would enable
     telemedicine technologies to be compatible, regardless of where
     they are developed;

  -- encourage adoption of appropriate standardized medical records
     and data systems so that information may be exchanged among
     sectors;

  -- overcome barriers so that investments can lead to better health
     care; and

  -- encourage federal agencies and departments to develop and
     implement individual strategic plans to support national goals
     and objectives. 

Further, because DOD is the major federal telemedicine investor and
manages one of the nation's largest health care systems, it is in a
good position to help forge an overall telemedicine strategy.  A
first step is to develop a departmentwide strategy.  Therefore, GAO
recommends that the Secretary of Defense develop and submit to
Congress by February 14, 1998, an overarching telemedicine research
and development and operational strategy.  The strategy should

  -- clearly define the scope of telemedicine in DOD;

  -- establish DOD-wide goals and objectives and identify actions and
     appropriate milestones for achieving them;

  -- prioritize and target near- and long-term investments,
     especially for goals related to combat casualty care and
     operations other than war; and

  -- clarify roles of DOD oversight organizations. 


   AGENCY COMMENTS AND GAO'S
   EVALUATION
---------------------------------------------------------- Chapter 0:6

GAO provided a draft of this report to DOD, VA, HHS, and the Office
of the Vice President.  Both DOD and VA concurred with our
recommendations.  DOD stated that it ".  .  .  is not alone in
finding itself behind the technological bow wave of telemedicine"
(see app.  III).  DOD said that one of its first priorities will be
the development of a definition and scope of DOD telemedicine
activities.  DOD also agreed to establish departmentwide goals and
objectives and prioritize investments as part of its strategic
telemedicine plan.  According to DOD, many pieces of this plan are
already in place.  VA commented that it would be beneficial for DOD
to include VA in its development of an operational strategy for
telemedicine activities (see app.  IV). 

After subsequent discussions with HHS officials regarding agency
comments, HHS generally agreed with the concept of our recommendation
for JWGT to play a leadership role in proposing national goals and
objectives.  HHS was concerned that a governmentwide strategy could
be overly prescriptive, given the evolving state of telemedicine
technology (see app.  V).  GAO's recommendation was not intended to
imply that JWGT direct federal agencies' investments in telemedicine
initiatives but rather that JWGT develop a roadmap for federal
agencies to use as a guide for their investments.  HHS also stated
that it might be better to require individual departments to develop
their own strategies before an overarching federal strategy is
proposed.  GAO believes that individual strategies should be
developed but that these strategies would not ensure an interagency
commitment to national goals and objectives or serve as a guide to
prevent duplicative investment efforts.  GAO further believes that
some agencies, such as DOD and VA, might be in a better position than
others to move forward with individual strategies, whereas other
agencies would benefit from an overall federal plan to help develop
their individual strategies. 

Also, GAO recommended that JWGT membership be expanded to include
private and state representation.  HHS expressed concerns about
implementing this portion of the recommendation due to requirements
in the Federal Advisory Committee Act.  Among other things, the act
would require reimbursement of any state and private sector
representative to attend the group's bimonthly meetings.  As a
result, GAO modified its recommendation by deleting suggestions to
expand JWGT beyond federal agency membership.  GAO believes that the
specific vehicle chosen is not important as long as the interaction
among the federal, state, and private sectors improves.  JWGT should
have the flexibility to choose the most effective vehicle for
fostering such interaction. 

Within the Office of the Vice President, the Chief Domestic Policy
Advisor and Senior Director for the National Economic Council did not
provide GAO with written comments.  The Senior Director for the
National Economic Council, however, raised questions regarding the
impact of the Federal Advisory Committee Act on expanding JWGT
membership to include private and state representation.  Further, DOD
and HHS provided specific technical clarifications that we
incorporated in the report as appropriate. 


INTRODUCTION
============================================================ Chapter 1

The influx of recent advanced communications technologies, coupled
with changing incentives in the health care marketplace, has resulted
in a resurgence of interest in the potential of telemedicine.  This
technology is expected to affect health care providers, payers, and
consumers in both the public and private sectors.  Telemedicine is
also expected to impact how medical care is delivered, who delivers
it, and who pays for it. 

Although many players throughout the federal government and the
private sector are involved in telemedicine, the Department of
Defense (DOD) is considered a leader in research related to
telemedicine efforts.  DOD has devised ways to use this new
technology to deliver health care on the battlefield or during
peacetime operations.  Currently, DOD has a major telemedicine effort
underway to provide medical support for U.S.  peacekeeping forces in
Bosnia. 


   WHAT IS TELEMEDICINE? 
---------------------------------------------------------- Chapter 1:1

As with other emerging technologies, telemedicine has not been
precisely defined.  An October 1996 Congressional Research Service
report noted that the definition of telemedicine continues to be
debated.\1 The problem centers on what to include in the concept. 
The essence of telemedicine is providing medical information or
expertise to patients electronically that would otherwise be
unavailable or would require the physical transport of people or
information. 

Telemedicine can be described in many different ways, depending on
the level of technology used, main purpose of its use, and
transmission timing.  At the lowest level, telemedicine could be the
exchange of health or medical information via the telephone or
facsimile (fax) machine.  At the next level, telemedicine could be
the exchange of data and image information on a delayed basis.  A
third level could involve interactive audio-visual consultations
between medical provider and patient using high-resolution monitors,
cameras, and electronic stethoscopes.  This level is currently
receiving much attention in literature and demonstrations. 

A more comprehensive telemedicine system would integrate all
components of technology for clinical, medical education, medical
information management (also called informatics), and administrative
services within a common infrastructure.  The relationship of these
components is shown in figure 1.1. 

   Figure 1.1:  Application
   Components of an Integrated
   Telemedicine System

   (See figure in printed
   edition.)


--------------------
\1 Telemedicine/Telehealth Description and Issues, Congressional
Research Service, 1996. 


   HISTORY OF TELEMEDICINE
---------------------------------------------------------- Chapter 1:2

Under its broadest definition, telemedicine has been practiced in
some form in the United States for almost 40 years.  Most projects
have demonstrated that this technology can be used to exchange
medical information between sites in both rural and urban settings. 
The first telemedicine project in the United States was established
in 1959, when the University of Nebraska transmitted neurological
examinations across campus.  In 1964, the university established a
telemedicine link with a state mental hospital 112 miles away.  The
National Aeronautics and Space Administration (NASA) was a
telemedicine pioneer in the 1960s with its satellite support of a
telemedicine project, conducted by the National Library of Medicine,
that provided health services to the Appalachian and Rocky Mountain
regions and Alaska.  In the 1970s, NASA also sponsored a project,
implemented with the Indian Health Service and the Department of
Health, Education, and Welfare, on an Indian reservation in Arizona. 

According to a report issued by the Institute of Medicine, only one
telemedicine project that started before 1986 has survived.\2
Evaluations of these projects indicated that the equipment was
reasonably effective and users were satisfied.  However, when
external funding sources were withdrawn, the programs could not be
sustained, indicating that the high cost of complex, technically
immature systems was a problem. 


--------------------
\2 Telemedicine:  A Guide to Assessing Telecommunications in Health
Care, Institute of Medicine, 1996. 


   CONGRESSIONAL AND EXECUTIVE
   INTEREST IN TELEMEDICINE
---------------------------------------------------------- Chapter 1:3

In 1993, several members of Congress established the Senate and House
Ad Hoc Steering Committee on Telemedicine to advise legislators on
integrating new technologies into health care reform strategies.  In
1994, the House Committees on Veterans Affairs and Science, Space,
and Technology held hearings to examine economic and legal barriers
that threatened to inhibit the expansion of telemedicine. 

In March 1995, the Vice President directed the Secretary of Health
and Human Services (HHS) to lead efforts to develop federal policies
that foster cost-effective health applications using communications
technologies, including telemedicine.  HHS was required to prepare a
report on current telemedicine projects, the range of potential
telemedicine applications, and public and private actions to promote
telemedicine and remove existing barriers to its use.  The Vice
President also directed that this effort include representatives from
several specific departments and agencies.  As a result, HHS
organized the Joint Working Group on Telemedicine (JWGT).\3 DOD is
providing the funding to carry out JWGT's taskings related to
constructing a telemedicine database.  In addition, other agencies
are providing personnel support.  HHS issued a status report on
JWGT's efforts to the Vice President in March 1996. 

In 1996, the Senate and House Ad Hoc Steering Committee on
Telemedicine sponsored a series of discussions by government and
private organizations on telemedicine issues, such as financing,
malpractice, and clinical standards.  Also, the Telecommunications
Act of 1996
(P.L.  104-104) directed the Secretary of Commerce, in consultation
with the Secretary of HHS, to submit a report to Congress by January
1997 concerning the activities of JWGT regarding patient safety; the
efficacy and quality of the services provided; and other legal,
medical, and economic issues related to the utilization of advanced
telecommunications services for medical purposes.  The Secretaries of
Commerce and HHS plan to jointly issue a final report to Congress and
the Vice President on January 31, 1997.\4

The Telecommunications Act of 1996 also directed the Federal
Communications Commission to explore actions that would provide basic
telecommunications services to all rural users.  The act further
required telecommunications companies to provide discounts to health
care providers in rural areas. 


--------------------
\3 In addition to HHS, federal departments or agencies represented in
JWGT include DOD, Veterans Affairs, Commerce, and Agriculture; NASA;
the Federal Communications Commission; and the Office of Management
and Budget.  In addition to federal participation, JWGT also contacts
private sector representatives involved in telemedicine to gain
consensus on key issues.  Among these groups are the American Medical
Association, the Physicians Insurers Association of America, Arent
Fox, RAND, the American College of Nurse Practitioners, and the
American Nurses Association. 

\4 The final report to Congress and the Vice President has been
issued. 


   OBJECTIVES, SCOPE, AND
   METHODOLOGY
---------------------------------------------------------- Chapter 1:4

As a result of congressional concerns about the federal government's
role in advancing telemedicine, the Chairman and Ranking Minority
Member, Subcommittee on Research and Development, House National
Security Committee, asked us to help determine the steps that DOD and
the federal government need to take to realize the full potential of
telemedicine and achieve cooperation with the private sector. 
Specifically, this report addresses the (1) scope of public and
private telemedicine investments; (2) telemedicine strategies among
DOD, other federal agencies, and the private sector; (3) potential
benefits that the public and private sectors may yield from
telemedicine initiatives; and (4) barriers facing telemedicine
implementation. 

Our overall approach was twofold.  First, we conducted a broad data
collection and analysis effort across nine federal departments and
agencies and selected private sector entities.  Second, we performed
a cross-cutting case study of DOD, other public agencies, and private
telemedicine projects in Georgia that provided us with examples for
each objective.  We chose Georgia because it had state, academic, and
private sector funding for telemedicine efforts as well as
collaboration with DOD on telemedicine projects.  We used a
comprehensive definition of telemedicine that included all four
applications of telemedicine linked together within a common
infrastructure.  We excluded the lowest level of this
technology--telephones and fax machines--from our data collection
efforts. 

To determine what role DOD and other federal agencies played in the
development of telemedicine, we collected and analyzed data on
ongoing federal projects and applicable funding levels for fiscal
years 1994-96.  We also interviewed officials within numerous DOD
components and eight federal departments and agencies.  In addition,
we reviewed DOD Inspector General reports, conference reports, and
relevant information available through the Internet. 

To determine the efforts of the public and private sectors to advance
telemedicine technology, we compared federal projects and funding
levels and efforts to identify redundancy among projects.  We
categorized federal projects by one of the components of telemedicine
identified through our analysis of definitions.  We reviewed relevant
literature on state and private sector efforts.  We held discussions
with state and private sector representatives involved with
telemedicine projects.  In addition, we attended bimonthly JWGT
meetings to keep abreast of its ongoing efforts. 

To obtain an overview of state programs, we interviewed state
officials and users from Georgia, North Carolina, and Texas who were
involved in their state's telemedicine network.  We also interviewed
officials of the Western Governors Association and George Washington
University on their recent study on state initiatives. 

To identify information on private sector involvement in
telemedicine, we interviewed officials and obtained data from many
national associations and organizations.  We also talked with
representatives from private sector health care facilities in Georgia
and Minnesota and equipment and telecommunications companies in
Georgia and the Washington, D.C., area. 

To determine the potential benefits of and barriers facing
telemedicine, we interviewed officials involved with telemedicine in
DOD, other federal and state agencies, and the private sector.  Also,
we analyzed telemedicine evaluations and studies of potential
barriers.  We did not validate potential cost savings data.  Appendix
I contains a comprehensive listing of all of the federal, state, and
private organizations we visited. 

We conducted our work from January to December 1996 in accordance
with generally accepted government auditing standards. 


MANY ENTITIES ARE INVOLVED IN
TELEMEDICINE, BUT THE TOTAL
INVESTMENT IS UNKNOWN
============================================================ Chapter 2

Numerous federal, state, and private organizations are sponsoring
hundreds of telemedicine initiatives, but the total investment is
unknown.  Even though the federal government's total investment
cannot be determined, we identified nine federal departments and
independent agencies that invested a minimum of $646 million in
telemedicine initiatives for fiscal years 1994-96.  During that time,
DOD invested the most, $262 million, followed by the Departments of
Veterans Affairs (VA), HHS, and Commerce, each investing over $100
million.  The focus of the investments varied depending on the
agency's mission, but most projects were directed toward medical
information systems, such as computerized patient records or
digitized imagery.  Other projects were directed toward
infrastructure development, clinical applications for rural or remote
areas, and medical education and training.  The Defense Advanced
Research Projects Agency (DARPA), working with some academic and
private sector entities, is doing unique near- and long-term research
for battlefield applications. 

Over 40 states have some type of telemedicine initiative underway
funded by federal agencies, the private sector, or the states
themselves.  Ten of these states, especially Georgia and Texas, have
taken an active role in sponsoring telemedicine initiatives. 
Estimates of telemedicine and related technology investments in the
private sector have not been quantified because telemedicine costs
are difficult to separate from health care delivery costs and most
cost data is proprietary.  Most private sector organizations,
including telecommunication companies, private hospitals, and managed
care organizations, have focused their telemedicine efforts on the
telecommunications infrastructure.  Other private sector efforts
include developing the computer and medical equipment needed for
telemedicine applications and delivering health care directly via
telemedicine. 


   FEDERAL INVESTMENT IS
   SIGNIFICANT BUT DIFFICULT TO
   DETERMINE
---------------------------------------------------------- Chapter 2:1

Estimating total costs for telemedicine is difficult because agencies
that deliver health care, such as VA, embed telemedicine costs within
their health care programs.  Also, the lack of a consistent
definition of telemedicine may result in an agency not including
certain project costs, whereas another agency would include the same
type of projects in its costs. 

We identified over 35 federal organizations within 9 departments and
independent agencies that were investing in telemedicine projects. 
Most officials from these departments did not know the amount their
departments had invested in telemedicine.  However, as table 2.1
shows, the federal government invested at least $646 million for
fiscal years 1994-96.  Details of federal telemedicine projects
appear in appendix II. 



                               Table 2.1
                
                Telemedicine Investments by Nine Federal
                 Departments and Independent Agencies,
                          Fiscal Years 1994-96

                         (Dollars in millions)

Department or agency                     FY 94   FY 95   FY 96   Total
--------------------------------------  ------  ------  ------  ------
DOD                                      $37.1  $106.5  $118.3  $261.9
VA                                        45.1    56.6    40.2   142.0
HHS                                       39.5    14.6    55.8   109.9
Commerce                                  56.1    46.2     3.6   106.0
NASA                                       1.0     3.3     2.3     6.6
Agriculture                                2.9     3.0     3.5     9.3
Justice                                      0       0     3.2     3.2
National Science Foundation                1.6     3.3     1.9     6.8
Appalachian Regional Commission            0.3       0       0     0.3
======================================================================
Total                                   $183.5  $233.6  $228.8  $646.0
----------------------------------------------------------------------
Note:  Figures do not add due to rounding. 

Source:  Our analysis of data from various sources within the federal
departments and agencies. 

Although some agencies have attempted to develop an inventory of
federal telemedicine projects, a governmentwide inventory has not
been completed.  For example, NASA had contracted with the Center for
Public Service Communications in 1993 to develop an inventory of
public and private telemedicine initiatives.  Funding was cut in
1994, and the inventory subsequently became outdated.  In 1995, the
DOD Inspector General developed a directory of DOD telemedicine
demonstrations and projects.  According to the DOD Inspector General,
this effort represented a starting point to track DOD's telemedicine
initiatives.  JWGT expected to complete a federal inventory in
January 1997. 


      DOD INVESTS IN BATTLEFIELD
      AND PEACETIME APPLICATIONS
-------------------------------------------------------- Chapter 2:1.1

DOD and each of the military services have collectively invested more
in telemedicine initiatives than any other federal department or
agency.  However, DOD and the services have not established
telemedicine budgets.  They currently initiate projects by
reprogramming funds from other programs and are developing budget
estimates for fiscal years 1998-2003. 

Nearly half of DOD's $262 million telemedicine investment was devoted
to unique long-term research and development of battlefield
applications of telemedicine.  For example, DARPA is developing
devices to treat wounded soldiers, such as a hand-held, physiologic
monitor that will help a combat medic locate a wounded soldier and
monitor the soldier's vital signs.  The Army is investing in the
development of a "virtual reality" helmet that will allow combat
medics to consult with a physician during the first critical hour,
referred to as the golden hour by DOD, after a soldier is wounded. 
The Navy has directed most of its telemedicine investments to
establish telecommunications connectivity between its deployed ships
and U.S.-based medical centers. 

The remaining DOD investment focused on peacetime health care.  The
Army, for example, is building medical communications networks to
link its medical centers with each other.  These networks will
support numerous medical functions, particularly digitized, filmless
x-rays or teleradiology.  The most significant Air Force telemedicine
effort will establish communications links between several Army,
Navy, and Air Force medical centers, hospitals, and clinics in
TRICARE Region 6.\1

DOD's investment helps provide medical care in several functional
applications within a telemedicine system, including clinical health
care delivery, medical information management, education, and
administration.  Figure 2.1 shows DOD's investment according to
functional application. 

   Figure 2.1:  Distribution of
   DOD's Telemedicine Investment
   by Functional Application

   (See figure in printed
   edition.)

Note:  Dollars are in millions. 

Source:  Various organizations within DOD. 


--------------------
\1 TRICARE is a DOD health care delivery plan that requires the Army,
the Navy, and the Air Force medical systems to pool resources to
provide quality health care that is accessible and affordable.  The
plan has 12 regions.  Region 6 supports Oklahoma, Arkansas, and major
portions of Louisiana and Texas.  Within this 4-state region, 19
military health care facilities support nearly 1 million
beneficiaries. 


      DOD'S INVESTMENT COULD
      INCREASE SIGNIFICANTLY
-------------------------------------------------------- Chapter 2:1.2

DOD's investment in telemedicine could double or even triple by the
year 2003 depending on key budget decisions to be made in fiscal year
1997.  Each service is currently developing its program objective
memorandum for fiscal years 1998-2003.  With regard to telemedicine,
the services estimate that $464 million will be needed for the
Theater Medical Information Program.  This program is designed to
link all the medical information systems within a battlefield or
operational theater, including medical command and control, medical
logistics, medical intelligence, blood management, and aeromedical
evacuation.  Such information will be used to collect and analyze
environmental health data, and the analysis will help battlefield
commanders make tactical decisions that may reduce disease and
non-battle-related injuries. 

The current deployment of telemedicine to Bosnia, known as
Primetime III, is an early test of some of the Theater Medical
Information Program's information management concepts.  For example,
Primetime III will use telemedicine to provide medical units access
to numerous medical capabilities at any time during the day or night. 
These capabilities include computerized medical records; full-motion
remote video consultation between theater medical units and tertiary
care facilities; far forward delivery of laboratory and radiological
results and prescriptions; digital diagnostic devices, such as
ultrasound and filmless teleradiology; and medical command and
control technologies. 

To achieve this access, DOD established an integrated electronic
network between (1) the Landstuhl Regional Medical Center in Germany,
(2) field hospitals in Hungary and Bosnia, (3) smaller brigade
operating base medical units and forward operating base medical
support units in Bosnia, (4) the U.S.S.  George Washington in the
Adriatic Sea, and (5) nine DOD medical centers located within the
continental United States and Hawaii.  To date, Primetime III
expenditures totaled $14.6 million--the Office of the Assistant
Secretary of Defense for Health Affairs funded $12.4 million, and
Army's 5th Corps in Europe funded $2.2 million.  Total costs are
estimated to be $30 million. 


      OTHER FEDERAL AGENCIES
      INVEST IN A RANGE OF
      TELEMEDICINE ACTIVITIES
-------------------------------------------------------- Chapter 2:1.3

Eight civilian federal departments or independent agencies with
various roles in providing or supporting health care delivery
invested $384 million in telemedicine from fiscal years 1994 to 1996. 
In some cases, these investments represented the estimated total
costs of projects for the year first awarded and not the costs
agencies actually incurred during those years.  Most expenditures
provided clinical services, telecommunications infrastructure, and
information management resources, as shown in
figure 2.2.  In many instances, the agencies' investments were
directed toward rural populations or focused on teleradiology. 

   Figure 2.2:  Distribution of
   Non-DOD Federal Investments by
   Telemedicine System Application

   (See figure in printed
   edition.)

Note:  Dollars are in millions. 

Source:  Various sources within the eight federal departments and
independent agencies. 


   STATE INVESTMENTS ARE GROWING
   BUT ARE NOT QUANTIFIED
---------------------------------------------------------- Chapter 2:2

In May 1995, the Primary Care Resource Center at George Washington
University completed a comprehensive review and analysis of the
states' telemedicine activities.  The report, entitled State
Initiatives to Promote Telemedicine, explores the role that states
have played in telemedicine and identifies their various initiatives,
but it does not quantify total investments. 

The study found that overall state involvement in telemedicine has
been expanding, particularly to provide health care to rural or
remote areas.  Although over 40 states have some initiatives underway
that are funded by federal agencies, the private sector, or the
states themselves, 10 actively sponsor telemedicine initiatives. 
Some states focus on the high costs of providing a telecommunications
infrastructure by requiring carriers to subsidize services to certain
educational and health care institutions, particularly in rural or
remote areas. 

We reported in 1996 that three states--Iowa, Nebraska, and North
Carolina--worked with the private sector and potential users to
encourage private investment and ensure the availability of services
in less densely populated areas.\2 These states encouraged private
investments in advanced telecommunications infrastructure by offering
to become major customers of these services from the telephone
companies.  As a result of the states' efforts, the telephone
companies made improvements faster than they would have on their own. 

Two states--Georgia and Texas--have well-established telemedicine
programs.  Georgia developed a statewide telemedicine network and
passed legislation to support telemedicine.  Texas owns and operates
some statewide networks and regulates the installation and costs of
its telecommunications infrastructure to support telemedicine. 
Another state--North Carolina--provides funding to a university that
is performing telemedicine consultations to the largest prison in
North Carolina and two rural hospitals


--------------------
\2 Telecommunications:  Initiatives Taken by Three States to Promote
Increased Access and Investment (GAO/RCED-96-68, Mar.  12, 1996). 


      GEORGIA
-------------------------------------------------------- Chapter 2:2.1

Georgia's telemedicine program began when the governor signed the
Georgia Distance Learning and Telemedicine Act of 1992, which
established a telecommunications network to ensure that all residents
of Georgia have access to quality education and health care.  The act
allowed the Public Service Commission to set a special flat-rate
structure across the state and allowed one communications company to
cross other companies' service areas to set up a statewide
infrastructure. 

The program received about $70 million from the state's Economic
Development Fund, which was established using fines paid by a
telecommunications company.  As of February 1996, approximately $9
million had been allocated for the telemedicine portion of the
network, and the remaining $60 million was spent on distance
education using telecommunications.  The telemedicine money funded
the network infrastructure, equipment for the sites, one-half of the
monthly line charges for the first 2 years of operations, and
one-half of the maintenance costs per site in the second year.  The
sites pay for personnel, administration costs, and remaining line
charges.  In addition, the state's Department of Human Resources
provides approximately $350,000 annually to advance telemedicine in
rural communities. 

The Georgia telemedicine network includes 60 sites serving 159
counties.  Seven of the sites are state correctional facilities. 
Three of these facilities have permanent telemedicine systems, with
the other four serviced by a mobile telemedicine van.  The network is
primarily used to provide inmates with more timely access to
specialty care.  Before telemedicine, non-emergency specialty care
services took 30 to 90 days to schedule.  With the implementation of
the system, inmates can see a specialist in 7 to 21 days. 

Several Georgia departments and agencies are actively involved in the
statewide network.  A governing board sets policies and awards
funding for the network.  The state's Department of Administrative
Services develops and administers the infrastructure network.  The
Medical College of Georgia plans, coordinates, and implements the
daily operations of the network's medical system, and the Office of
Rural Health and Primary Care, within the Department of Human
Resources, approves proposed expenditures, ensuring that funding is
used entirely to advance telemedicine in rural communities. 


      TEXAS
-------------------------------------------------------- Chapter 2:2.2

Texas uses state-operated networks to provide telemedicine
consultations and continuing medical education to small rural
clinics.  For example, the University of Texas Health Science Center
at San Antonio operates the South Texas Distance Learning and
Telehealth infrastructure network.  In addition, the Texas Tech
Health Sciences Center and the University of Texas Medical Branch at
Galveston provide all of the medical care to the 130,000 inmates at
104 state prison facilities.  These facilities have physicians and
other clinical staff to provide primary care, but patients who
require specialized care are referred to the Galveston and Texas Tech
hospitals.  The state has funded a telemedicine project to link
specialists in Galveston with four state prisons and has plans to
expand the project to other locations.  Texas officials estimated
that telemedicine has greatly reduced the number of patients
transferred from their home facilities to the hospitals. 

The state has arranged with the private owners of the
telecommunications systems to charge a flat rate for usage. 
Specifically, rural clients and other low utilization users are
charged $425 per month for up to 40 hours of usage.  Commercially, a
facility would pay an access charge of $475 plus a use charge of $60
to $100 per hour. 


      NORTH CAROLINA
-------------------------------------------------------- Chapter 2:2.3

In 1992, the East Carolina University Medical School began providing
telemedicine consultations to the state prison in Raleigh, 100 miles
away.  Physicians see and talk to the patients via the telemedicine
link and then diagnose and prescribe medications when necessary.  A
digital stethoscope, graphics camera, and miniature hand-held
dermatology camera are used to aid patient examinations.  These
tools, along with a computerized patient record system and a
comprehensive scheduling system, form the basis of an integrated
health care information system being implemented across a wide area
network in North Carolina.  The model developed for the prison system
is now being expanded to six rural hospitals within the state and the
naval hospital at Camp Lejeune. 


   PRIVATE SECTOR IS INVESTING
   MOSTLY IN INFRASTRUCTURE
---------------------------------------------------------- Chapter 2:3

Estimates of private sector investments have not been quantified
because telemedicine costs are difficult to separate from health care
delivery costs and most cost data is proprietary.  The Koop Institute
estimates that the U.S.  telemedicine market totals $20 billion for
telecommunications infrastructure, computer hardware and software,
and biomedical equipment.  A breakdown of this funding is
unavailable.  Further, any estimate of private sector investments
would partially duplicate amounts reported by the public sector
because of contract and grant relationships.  Also, the Koop
Foundation, a sister organization to the institute, is expected to
compile an inventory by the year 2000 of private sector telemedicine
projects.\3

Dozens of private interests, including telecommunications companies,
equipment manufacturers, private hospitals, and managed care
organizations, have positioned themselves to capture future
telemedicine market shares.  For example, telecommunications
companies are providing the infrastructure that allows telemedicine
consultations and data transfers to occur.  Private companies built
and own the National Information Infrastructure and lease the lines
to telemedicine users and others.\4 Most telemedicine end users do
not own high-technology telecommunications lines and thus rely on
private enterprise to provide this infrastructure. 

Equipment manufacturers use their own funds and federal financial
support to develop data transmission technologies, such as digital
coding and decoding equipment, to facilitate telemedicine
consultations.  Private firms also develop medical sensory devices,
such as electronic stethoscopes, specialized cameras, and robotic
surgical assistance devices. 

Until recently, most telemedicine efforts in the health care delivery
area either received some federal or state funds or were limited to
teleradiology.  Some providers have now invested in their own
telemedicine networks, seeking to achieve cost and operational
efficiencies.  For example, a large managed care organization in
Minnesota established telemedicine networks between its facilities to
expand specialty care to members in rural areas.  Another provider
established telemedicine links among its three facilities in
Minnesota, Florida, and Arizona and became one of several health care
providers seeking to expand to international telemedicine linkages. 

One manufacturer of medical robotics, Computer Motion, Inc., believes
that improved automation has been fundamental in opening huge new
markets.  For example, many surgeons, nurses, and medical assistants
all see the use of robotics for laparoscopic surgery as extremely
positive.  The movements of the laparoscope are smooth, and the video
image remains steady throughout the procedure.  The physician who, in
August 1993, performed the first laparoscopic surgery using the
robotic arm said the biggest advantage is that surgeons have complete
control and do not have the difficult task of communicating to
assistants where to move the laparoscope.  Literature indicates that
giving directional instructions can be a distraction from the
procedure itself; most surgeons can be more efficient if they do not
have to keep asking someone to correct the positioning of the scope. 

The manufacturing company has been working closely with Yale
University in support of research and education programs in
telesurgery and robotically assisted laparoscopy.  One university
official said that the partnership would allow the university to
bring robotics into the education system and demonstrate how it could
be used effectively to reduce costs and improve the quality of
patient care. 

Medical robotics continues its rapid expansion into the worldwide
marketplace.  European countries and various training centers have
begun to launch collaborative efforts in medical robotics education. 
According to the manufacturer, more than 100 robotic arms have been
used in approximately 13,000 minimally invasive surgical procedures. 
Voice control will be a feature of the next generation of robotic
arms, which will require clearance by the Food and Drug
Administration (FDA). 


--------------------
\3 Former Surgeon General C.  Everett Koop, in response to requests
from the White House and private sector, formed a health informatics
initiative to foster and facilitate public and private sector
leadership in the health component of national and global information
infrastructures. 

\4 The National Information Infrastructure consists of a physical
system of telecommunications pathways and connections that transmit
and receive voice, video, and data.  The administration's goal for
the infrastructure is to interconnect industry, government, research,
education, and each home with advanced telecommunications networks
and information resources. 


FEDERAL GOVERNMENT DOES NOT HAVE A
STRATEGY TO MAXIMIZE VALUE OF
TELEMEDICINE INVESTMENTS
============================================================ Chapter 3

No overarching, governmentwide strategy exists to ensure that the
most is gained from numerous federal telemedicine efforts.  Until
recently, there was little or no coordination of telemedicine
activities among federal agencies.  Although JWGT is a first step
toward providing a mechanism to help coordinate federal support of
telemedicine, federal departments have not developed agencywide
strategies to manage their own telemedicine efforts.  Without clear
goals and priorities for telemedicine investments, some programs are
difficult to justify and may be in jeopardy. 

Federal agencies have recognized the need for a strategic plan to
fulfill their telemedicine visions.  Even as the largest single
federal investor and perhaps the main sponsor of long-term
telemedicine research, DOD does not have a plan to ensure it is
maximizing the value of its investments.  As a result, DOD's (1)
organizational structure to ensure the infusion of telemedicine into
application is still evolving, (2) telemedicine program has not been
precisely defined, (3) budgets do not reflect a comprehensive
telemedicine program, and (4) partnerships with the private sector
have not been fully explored.  DOD's telemedicine experiences may be
indicative of telemedicine activities throughout the federal
government.  In addition, the private sector has recognized that
telemedicine technologies have developed to the point at which
telemedicine strategies are needed to guide investments. 


   OVERALL FEDERAL TELEMEDICINE
   EFFORT IS NOT WELL COORDINATED
---------------------------------------------------------- Chapter 3:1

No formal mechanism or strategic plan exists to ensure that
telemedicine development is fully coordinated among federal agencies
and that telemedicine efforts have a common purpose.  A
well-coordinated plan is important because over 35 federal government
organizations directly or indirectly conduct or sponsor (1) research
and development; (2) demonstrations using telemedicine for health
care delivery; or (3) evaluations of telemedicine's effects on the
quality, accessibility, cost, and acceptability of health care.  Some
of the involved federal organizations are shown in table 3.1. 



                                    Table 3.1
                     
                        Federal Organizations Involved in
                             Telemedicine Initiatives

                                                   Conducts or sponsors
                                           -------------------------------------
                                              Research
                                                   and  Health care
Organization                               development     delivery  Evaluations
-----------------------------------------  -----------  -----------  -----------
Office of the Secretary of Defense for               X            X            X
 Health Affairs (DOD)
DARPA (DOD)                                          X
Medical Research and Materiel Command/               X            X            X
 Medical Advanced Technology Management
 Office (DOD)
Offices of the Surgeons General (DOD)                             X            X
Army Medical Command (DOD)                                        X            X
Military hospitals (DOD)                                          X            X
Armed Forces Institute of Pathology (DOD)                         X
U.S. Transportation Command (DOD)                                 X
Veterans Health Administration (VA)                               X            X
Rural Utilities Service (Agriculture)                             X
National Telecommunications and                      X
 Information Administration (Commerce)
National Institute of Standards and                  X
 Technology (Commerce)
FDA (HHS)                                                                      X
Health Care Financing Administration                              X            X
 (HHS)
Agency for Health Care Policy and                    X                         X
 Research (HHS)
Indian Health Service (HHS)                                       X
National Library of Medicine (HHS)                   X                         X
Office of Rural Health Policy (HHS)                               X            X
Bureau of Prisons (Justice)                                       X
NASA                                                 X            X
National Science Foundation                          X
Appalachian Regional Commission                                   X
--------------------------------------------------------------------------------
The organizations involved with telemedicine initiatives are seeking
solutions to narrowly defined problems that fall under their purview. 
For example, the Department of Justice, specifically the Federal
Bureau of Prisons (BOP), is responsible for the detention and care of
approximately 95,000 prisoners, nearly 4,000 of whom receive medical
attention on any given day.  A small but growing percentage of these
prisoners must currently be moved under guard from detention sites to
distant medical facilities for diagnosis and treatment.  BOP is
interested in telemedicine because of the opportunity to reduce the
significant cost of providing medical care to prisoners.  In
addition, telemedicine offers the chance to reduce the number of
times prisoners are taken to outside medical facilities, thus
reducing the potential for escape and risk to the attending medical
staff and citizens within the local communities. 

Other organizations are using telemedicine to meet their mission
needs.  For example, NASA is interested in telemedicine primarily to
understand its application to medical care in space for future
long-duration platforms, such as a space station, and minimize the
risk of inadequate medical care for astronauts, which would increase
the probability of mission success.  The Department of Commerce has
two core programs that promote private sector development of advanced
telecommunications and information technologies for health-related
projects.  Within the Department of Agriculture, the Rural Utilities
Service plays a key role in the rural aspect of the National
Information Infrastructure.  One grant awarded in 1996 will help the
Rural Utah Telemedicine Associates to implement a mobile health
clinic that will provide primary care and specialty consultation via
telemedicine technology to rural communities with few or no health
care providers. 

Some interagency coordination occurs on an ad hoc or narrow basis
(e.g., through symposiums, technology demonstrations, and joint
programs), but this approach does not necessarily provide a firm
basis for technology exchange.  Many agency officials we met with
cited the lack of an established coordination mechanism as an
obstacle to determining information that could help advance
telemedicine.  Further, some agency officials were concerned about
possible redundant efforts, especially those related to
teleradiology--the most common current application of telemedicine
supported by federal funds.  However, the officials lacked
information to determine whether the work was redundant or actually
complemented other's efforts.  Several agency officials said that
some federal telemedicine efforts repeated previous mistakes rather
than benefited from them because information on previous efforts was
not available. 

To help fill the information gap, DOD funded JWGT's project to
develop a database of all federally funded telemedicine projects. 
JWGT considers such an inventory a critical first step toward
achieving coordination across federal agencies.  The database should
allow federal agencies to more easily learn about the federal
investment in various telemedicine projects.  JWGT will make this
database available to the public on the Internet to assist states and
communities with their own telemedicine plans. 

Because of the magnitude of the federal government's involvement in
telemedicine development, JWGT has thus far been unable to develop an
accurate, comprehensive inventory of federal projects.  JWGT believes
that its efforts to develop an inventory have demonstrated the
weaknesses in the information maintained by federal agencies and
highlighted the need for greater attention to routine data collection
on federally funded programs.  For example, departments or agencies
have many different definitions of telemedicine, making it difficult
to collect compatible data.  The inventory, originally scheduled for
release in June 1996, was expected to be released by the end of
January 1997.  JWGT stated that each participating agency would be
responsible for maintaining the inventory.  However, members of JWGT
have expressed concern as to whether each of the agencies would be
supportive of maintaining their inventories. 

In addition, JWGT meets approximately twice a month to help
coordinate federal telemedicine activities and share relevant
information.  JWGT meetings include over 60 individuals representing
executive branch agencies.  However, no representatives from each
service's Surgeon General's office or DARPA attend these meetings. 
Further, private sector participation was limited mostly to
professional medical associations. 


   FEDERAL AGENCIES RECOGNIZE THE
   NEED FOR DEPARTMENT STRATEGIES
---------------------------------------------------------- Chapter 3:2

In addition to the lack of an overall federal telemedicine strategy,
federal agencies do not have departmentwide strategies to maximize
the value of their telemedicine investments.  If each agency involved
in telemedicine had its own strategy, a governmentwide strategy could
be built from it.  The absence of departmentwide strategies has
contributed to unclear definitions of telemedicine and the lack of a
comprehensive inventory of telemedicine projects among all involved
federal agencies.  DOD, as well as other federal agencies, are
beginning to recognize that an intra-agency strategy may be the first
step to target their investments in telemedicine. 


      DOD
-------------------------------------------------------- Chapter 3:2.1

According to the Assistant Secretary of Defense for Health Affairs,
who oversees the Military Health Services System (MHSS), telemedicine
will be a major enabling technology in reengineering health care
delivery in DOD and throughout the United States.\1 The Assistant
Secretary believes that a mature telemedicine infrastructure can
reduce health care delivery costs, but mechanisms must be put in
place to manage the infusion of telemedicine into application while
still proceeding with appropriate research and development or
prototype efforts.  However, no such mechanisms are currently in
place in DOD. 

DOD has recognized the need for a strategic plan to fulfill its
telemedicine vision, as stated in the December 1994 testbed plan
published by the U.S.  Army Medical Research and Materiel Command. 
This document also stated that the Telemedicine Technology
Integrating Committee, led by the Commanding General of the Medical
Research and Materiel Command, would develop a plan that would
provide a framework for multispecialty integration of entrepreneurial
efforts and ensure the optimum use of scarce resources for DOD's
peacetime and wartime medical activities.  However, no milestones
were established for accomplishing this plan. 

Health Affairs officials told us that they are responsible for
developing an overall strategic plan for telemedicine.  As of
December 1996, the Assistant Secretary of Defense for Health Affairs
had not approved this plan.  Officials told us that the DOD
telemedicine organizational structure resulting from this plan would
be modeled after the one established for DOD's information management
and information technology systems.  However, no other details were
available. 

Some defense organizations have begun developing their own strategic
plan.  For example, in June 1996, the Center for Total Access, which
includes TRICARE Region 3 and the Army's Southeast Regional Medical
Command, published a 5-year strategic plan to support both
commands.\2 The plan recognizes the need for telemedicine projects to
adhere to specific guidelines and provides a framework for ensuring
that the projects and initiatives undertaken conform to an open
standards environment and that new telemedicine initiatives can
easily be integrated with existing systems.  However, this regional
telemedicine plan could be fundamentally different than the strategic
plans of the other 11 TRICARE regions. 

Many officials expressed concern as to how telemedicine would be
integrated into the continuum of DOD medical care--from the
battlefields overseas to the medical treatment facilities in the
United States--with so many activities underway and no overriding
strategy to link them together.  For example, the Army Medical
Department must provide mobile, flexible support for its own forces
across long distances in a variety of wartime environments.  The Army
has developed a mission needs statement for medical communications in
combat casualty care and established a program manager under an Army
program executive office for this work.  The Air Force's medical
forces are responsible for most of the air evacuations from the
theater of operations to the United States in wartime, but the Air
Force is not part of the Army's medical communications initiative. 
Army officials acknowledged that this initiative should eventually be
a triservice program.  Further, no parallel mission needs statement
ensures the continuum of care from theater to the continental United
States. 

Without a formal strategy to define the goals and objectives of DOD's
telemedicine initiatives, some DOD programs may be difficult to
justify and therefore may be in jeopardy.  For example, research and
development efforts led by DARPA are subject to discontinuation due
to a change in the agency administrator's priorities.  DARPA
initiated its telemedicine efforts in fiscal year 1994 with a defined
program to find ways to improve medical care on the battlefield. 
Even though DARPA's efforts are starting to mature, there is no clear
plan regarding how individual projects will be infused into
application.  DARPA will be looking to the individual services to
continue its research and development function. 


--------------------
\1 MHSS is one of the nation's largest health care systems, offering
health benefits to about 8.3 million people and costing over $15
billion annually.  The primary mission of MHSS is to maintain the
health of military personnel so they can carry out their military
missions and be prepared to deliver health care during a time of war. 
MHSS can also provide health care services in DOD medical treatment
facilities to dependents of active duty servicemembers and retirees
and their dependents. 

\2 Region 3 supports South Carolina, Eastern Florida, and Georgia. 
It contains 14 triservice medical treatment facilities and provides
benefits to over 1 million beneficiaries.  The Southeast Regional
Medical Command consists of the same states plus Alabama, Kentucky,
Mississippi, and Tennessee and an additional four medical treatment
centers. 


      OTHER FEDERAL AGENCIES
-------------------------------------------------------- Chapter 3:2.2

NASA, a pioneer in developing telemedicine technologies for almost
40 years, is developing a strategic plan for its telemedicine
initiatives.  The plan will address the use of telemedicine in the
human space flight program and the use of NASA-developed technology
in telecommunications, computers, and sensors to enhance health care
delivery for humans in space.  The plan will also incorporate
industry input into these areas. 

According to 1994 VA testimony, the use of telemedicine is having a
major impact on VA's approach to health care, but VA does not have a
telemedicine strategic plan.  To provide overall leadership to its
telemedicine program, VA recently established the position of Chief
of Telemedicine.  This official serves as the principal advisor on
telemedicine to the Offices of the Under Secretary for Health,
Patient Care Services, and Chief Information Officer.  VA officials
told us that the Chief of Telemedicine would develop a strategic
plan.  Other responsibilities of the Chief include facilitating the
coordination of VA facilities undertaking telemedicine projects;
overseeing VA activities regarding selection, funding, and evaluation
of telemedicine projects; consulting with medical centers about the
application of telemedicine standards; and identifying needs for
telecommunications and infrastructure support. 

HHS does not have a strategic plan linking the efforts of its six
agencies investing in telemedicine.  HHS officials believe that JWGT
effectively communicates information about telemedicine development
to the six applicable HHS agencies.  However, agency officials
acknowledged that a strategic plan may be needed.  The officials also
stated that such a plan should strengthen, support, and build on the
work of JWGT and not create a new bureaucracy. 


   DOD'S TELEMEDICINE EFFORTS ARE
   DIFFUSED AND WEAKLY LINKED
---------------------------------------------------------- Chapter 3:3

Although DOD has a large and growing investment in telemedicine, it
has not yet structured its telemedicine initiatives, which are led by
numerous organizations, to determine if, collectively, their cost is
commensurate with potential benefits DOD stands to gain.  Within DOD
(1) the roles of numerous key players are still evolving, (2) the
telemedicine domain is unclear, (3) comprehensive program budgeting
has not occurred, and (4) partnerships with the private sector have
not been fully explored.  Further, DOD's telemedicine activities may
be indicative of other federal agencies' telemedicine efforts. 


      ORGANIZATIONAL
      RESPONSIBILITIES ARE STILL
      EVOLVING
-------------------------------------------------------- Chapter 3:3.1

Many different DOD organizations generate telemedicine projects,
including the ones shown earlier in table 3.1.  The problems of
organizational responsibilities are exacerbated by the large number
of organizations involved in telemedicine activities. 

In September 1994, the Assistant Secretary of Defense for Health
Affairs designated the Army Surgeon General as the DOD Executive
Agent for telemedicine and established the "DOD Telemedicine Testbed
Project" to explore and develop new clinical approaches for using
telemedicine.  The Commander of the Army's Medical Research and
Materiel Command was designated as the testbed's Chief Operating
Officer, and the Command's Medical Advanced Technology Management
Office (MATMO) was designated the principal manager and administrator
for the testbed.  However, the responsibilities for the Executive
Agent, Chief Operating Officer, and MATMO were never approved in a
charter. 

Air Force, Navy, and other agency officials told us that an office
similar to MATMO is needed to bring focus and coordination to
telemedicine within DOD.  They also said that MATMO has been too
focused on mainly supporting Army deployable telemedicine projects
and excluding the other services' needs.  It was difficult for us to
distinguish between what MATMO initiates for the DOD-wide testbed and
what it is pursuing for the Army.  Most of MATMO's accomplishments
are associated with the Medical Diagnostic Imaging Support system,
which the Medical Research and Materiel Command was involved with
before the Army became the DOD Executive Agent for telemedicine.\3

Further, many service officials we met with, except from specific
Army programs, were either not familiar with MATMO or were not
getting guidance from them.  For example, the Air Force program
manager responsible for initiating a program in TRICARE Region 6,
which Health Affairs expects to be a model for other TRICARE regions,
had not received any assistance from MATMO in designing the program. 
The official told us that he relied on officials from the Medical
College of Georgia for assistance.  In addition, Navy telemedicine
program officials at Camp Lejeune, North Carolina, were familiar with
MATMO but relied on East Carolina University for advice.  Further,
this official stated that a group of TRICARE regions were attempting
to develop their own coordinating mechanism on the Internet. 

Other layers of oversight have evolved without clear
responsibilities, with the Army fulfilling many key positions. 
Executive oversight of the testbed was vested in a Board of
Directors, chaired by the Assistant Secretary of Defense for Health
Affairs.  Board members include the Director, Defense Research and
Engineering; the Assistant Secretary of Defense for Command, Control,
Communications, and Intelligence; the Joint Staff Director for
Logistics; the three Surgeons General; and the Director of DARPA.  At
one point the Army Surgeon General served as both the Executive
Secretary of the Board and as the Chief Executive Officer of the
testbed.  With the retirement of the former Army Surgeon General, the
Navy Surgeon General became the Chief Executive Officer.  However,
the Chief Executive Officer's responsibilities have not been defined. 

In addition, the Army Medical Department and MATMO had been
responsible for overseeing evaluations of telemedicine projects, such
as those being demonstrated in Bosnia.  Army officials informed us
that this responsibility was being transferred to another service; as
a result, the future of some of the Army's and MATMO's efforts was
undecided.  Other officials told us that the change was being made to
prevent any conflict of interest on the Army's part, since the Bosnia
telemedicine deployment is primarily an Army effort. 

In August 1996, Health Affairs officials told us that its Information
Management Proponent Committee would soon be responsible for
providing oversight of telemedicine initiatives, including those
under MATMO's purview.  However, officials could not provide
additional insight at that time regarding the concept of this
structure. 

In addition, another organizational change is underway that will
impact on telemedicine, including DOD's research and development
initiatives.  In June 1996, the Deputy Secretary of Defense directed
the Army to take the lead in establishing an Armed Forces Medical
Research and Development Agency.  The future impact of this new
agency on the organizations responsible for telemedicine functions
and funding is unknown. 


--------------------
\3 The Medical Diagnostic Imaging Support is a filmless radiology
system that has been operational at Madigan Army Medical Center at
Fort Lewis, Washington--its first test site--since 1992.  The system
is also in operation at Walter Reed Army Medical Center, Washington,
D.C.; Wright-Patterson Medical Center, Dayton, Ohio; Brooke Army
Medical Center, San Antonio, Texas; and Tripler Regional Medical
Center, Honolulu, Hawaii. 


      TELEMEDICINE DOMAIN IS
      UNCLEAR
-------------------------------------------------------- Chapter 3:3.2

A 1995 DOD Inspector General report suggested that DOD needed to
define telemedicine more clearly.\4 Without a consistent definition
to describe telemedicine initiatives, responsible officials from the
various DOD organizations participating in telemedicine efforts do
not know precisely what their programs encompass.  Although defense
officials generally agree that telemedicine involves the use of
communications technology to deliver health care, they have not
agreed on the types of initiatives to include within the scope of
telemedicine oversight.  For example, some Army and DARPA officials
consider patient identifiers that allow the electronic storage of
medical information on a card or dog tag-like device to be the first
element in an integrated telemedicine system, but the Navy does not
view these devices in the same manner. 

Air Force officials initially classified one of their projects as
telemedicine but later said that the project fell outside of its
definition of telemedicine.  The project, called Provider
Workstation, is intended to provide medical personnel with the
capability to access medical records on a personal desktop computer
no matter where the patient or the relevant information is located. 
Air Force officials now identify this project as one of its many
medical management information systems.  However, a 1996 DOD
Inspector General report noted that Provider Workstation was a
successful DOD telemedicine project.\5

Although MATMO tried to identify the full scope of telemedicine
projects that might fall within its oversight function, our analysis
revealed that its inventory (1) did not include the services' actual
telemedicine efforts and DARPA-initiated projects and (2) contained
inaccurate information.  During the course of our review, MATMO and
Health Affairs provided us information on six different inventories
that included anywhere from 22 to 94 projects.  In addition, a Health
Affairs official told us that Health Affairs did not directly fund
any telemedicine projects, but several telemedicine project managers
informed us that they received funding from Health Affairs. 


--------------------
\4 Telemedicine Demonstrations and Projects Directory, Department of
Defense, December 1995. 

\5 Evaluation Of Areas Of Consideration For A Department Of Defense
Clinical Telemedicine Needs Assessment, Department of Defense,
February 1996. 


      PROGRAM BUDGETING HAS NOT
      OCCURRED
-------------------------------------------------------- Chapter 3:3.3

DOD has not developed a comprehensive telemedicine budget or program
objective memorandum.  In a 1994 memorandum to the Army Chief of
Staff, the Director for Program Analysis and Evaluation noted that
the concept of telemedicine needed to be defined by the Office of the
Army Surgeon General to compete for funding during the budget
process.  Funding for telemedicine has been derived from other
programs or congressionally directed. 

Some service officials are especially concerned about budgeting for
MATMO projects because MATMO managed about $47 million during fiscal
years 1995 and 1996 in telemedicine initiatives that were funded by
Health Affairs or reprogrammed through the Medical Research and
Materiel Command.  Service officials have pointed out that MATMO does
not have an approved funding line and therefore can operate outside
the normal DOD development and acquisition process.  As a result,
none of MATMO's telemedicine projects are subject to milestone
decisions, cost-benefit analyses, or life-cycle management decisions,
which are all required in the acquisition process.  MATMO officials
believe that their approach is necessary at this time because
technology is changing at such a fast pace that the normal
acquisition cycle would prevent DOD from capitalizing on the newest
telemedicine technology. 


      PARTNERSHIPS WITH THE
      PRIVATE SECTOR HAVE NOT BEEN
      FULLY EXPLORED
-------------------------------------------------------- Chapter 3:3.4

Other than the telemedicine initiatives led by DARPA, few
partnerships between the private sector and DOD are planned.  The
Medical Research and Materiel Command attempted to promote a
collaborative working relationship between the Army and the private
sector.  The Command was planning to develop state-of-the-art
telemedicine technologies--called the U.S.  Army Federated Laboratory
Concept--that are focused on combat casualty care.  In May 1995, the
Command issued a broad agency announcement.  Interested parties were
required to form consortiums involving health service providers,
industry, and academia.  Two parties whose proposals had not been
accepted stated that DOD needed a more defined plan to which the
private sector could respond.  However, funding for the laboratory
concept had not been programmed and was therefore subject to the
availability of reprogrammed funding. 

Although the Navy is seeking to form partnerships with academia,
industry, and other government agencies, East Carolina University
School of Medicine and Pitt Memorial Hospital, instead of Portsmouth
Naval Medical Center, took the initiative to integrate the Camp
Lejeune Naval Hospital in a telemedicine network.  The TRICARE region
that encompasses Camp Lejeune does not have a telemedicine strategy
that identifies goals for pursuing such partnerships. 

Also, according to Army Medical Department officials, the Army's
Great Plains Health Service Support Area, responsible for managing
medical care at Army facilities in 14 states and Panama City, has
attempted to establish cost-sharing agreements with Texas Tech and a
VA clinic in the area, but these attempts have been unsuccessful
because of the lack of clear goals and objectives. 


   PRIVATE SECTOR TELEMEDICINE
   STRATEGIES ARE EVOLVING
---------------------------------------------------------- Chapter 3:4

Given the wide range of private sector players in the implementation
of telemedicine, it is understandable that no single private sector
strategy exists to advance this emerging technology.  For example,
manufacturers develop new products, utility companies build the
telecommunications infrastructure, professional organizations develop
health care standards, health providers deliver medical care, and
special interest groups promote the use of new technologies.  Each of
these groups has its own interests and strategies for advancing
telemedicine. 

Nonetheless, the private sector is an important player in furthering
the development and application of telemedicine technologies.  Two
private sector health care providers--the Mayo Clinic and Allina
Health Systems--and a major telecommunications company--American
Telephone and Telegraph (AT&T)--illustrate the critical role played
by the private sector in advancing telemedicine and developing
strategies for greater usage of this emerging technology. 


      MAYO CLINIC
-------------------------------------------------------- Chapter 3:4.1

Telemedicine at the Mayo Clinic evolved to facilitate integration of
group practices at three separate locations--Jacksonville, Florida;
Scottsdale, Arizona; and Rochester, Minnesota.  In 1986, the Mayo
Foundation installed a satellite-based video system that enabled
physicians, researchers, educators, and administrators to communicate
with each other.  When the Jacksonville and Scottsdale facilities
were not fully staffed, they used specialists from Rochester via
telemedicine for four or five consultations per week.  However, with
the addition of specialists at the Jacksonville and Scottsdale
locations, the telemedicine system was increasingly used for
education, research, and administrative purposes.  According to Mayo,
in 1995, its telemedicine system was used for over 700 telemedicine
consultations in echocardiology between Rochester and the other two
sites. 

Mayo is also involved in a project supported by NASA and DARPA to
explore the combination of satellite communication and terrestrial
services in an economic telemedicine model.  To conduct the project
successfully, Mayo has assembled a consortium of leaders in the
industry (Hewlett-Packard, General Electric Medical Systems, Sprint,
U.S.  West, Martin Marietta, Healthcom, and Good Samaritan Hospital
in Arizona), along with Mayo Foundation entities.  The results from
this project will help determine a strategic policy for telemedicine
at the Mayo Clinic and provide knowledge about the use of
asynchronous transfer mode technology for local area and wide area
networks.  Mayo officials told us that there has to be a need for
which telemedicine is a solution--otherwise telemedicine applications
will not be financially viable.  These officials believed that
managed care organizations may ultimately drive the development of
telemedicine. 


      ALLINA HEALTH SYSTEMS
-------------------------------------------------------- Chapter 3:4.2

A representative from Allina Health Systems, a managed care
organization and insurer from Minneapolis, Minnesota, stated that the
market will determine the pace and extent to which it expands its
telemedicine services.  Along with an alliance of eight rural
hospitals, Allina has operated since 1995 a telemedicine network that
links hospital emergency rooms.  Allina believes that emergency
medicine in rural areas is the best application of telemedicine
currently available for its operation.  As of October 1996, Allina's
telemedicine network had been used for about 130 medical
consultations and about 450 emergency service consultations. 
Allina's network is a single-state system, which eliminates concerns
about licensure requirements that plague many telemedicine efforts. 
The use of Allina's telemedicine network in urban areas is quite
different than its use in rural areas.  For example, in urban areas
there is more extensive use of the system for administrative and
educational purposes and virtually no use for consultative purposes. 

Allina recognizes the need for better cost-benefit data to justify
major investments in telemedicine and prove that the applications are
worthy.  Toward this goal, the company plans to improve the
development of project evaluations and its marketing strategy. 

Allina must decide in the near future whether to view its
telemedicine initiative as a service and thus a cost of business or
as a separate business entity or profit center.  One of the
complicating issues is that so many variables in measuring costs are
difficult to separate (i.e., normal operating costs versus special
costs associated specifically with telemedicine). 


      AT&T
-------------------------------------------------------- Chapter 3:4.3

AT&T's strategy for telemedicine development involves developing
services for telecommunication applications, transactions, and
networking and providing telecommunications and some training for
computer-based medical systems.  These efforts have accelerated since
the creation of the National Information Infrastructure.  AT&T's
involvement in telemedicine efforts is largely due to the company's
perception, which was confirmed by clients, of a need for reliable
and secure communication lines for health care. 

AT&T is making a substantial investment--both financially and from a
personnel resource perspective--in telemedicine development.  For
example, an official told us that by December 1996 AT&T expected to
assign about 100 staff members to servicing or managing one agency's
telemedicine system. 

Even though it has contracts with federal agencies and is assisting
many private sector groups, AT&T plans to seek FDA review of its
products and services.  AT&T said that many products involving
telemedicine are possible but that customers may not be willing to
pay for them.  As a result, manufacturers must make certain that
there is a market for the products being developed. 


   AGENCY COMMENTS AND OUR
   EVALUATION
---------------------------------------------------------- Chapter 3:5

HHS commented that our report should acknowledge the role that the
High Performance Computing and Communications Program has played in
the coordination of federal telemedicine research and development
activities.  During our review, we collected data from the National
Library of Medicine on funding from this program specifically for
telemedicine initiatives.  However, agency officials did not
highlight to us the role that this program plays in coordination of
telemedicine activities across the federal government or with JWGT. 
We believe that the program is one of several federal initiatives
supporting telemedicine initiatives.  However, we did not evaluate
the program, since it was beyond the scope of our review. 


TELEMEDICINE BENEFITS ARE
PROMISING BUT LARGELY UNQUANTIFIED
============================================================ Chapter 4

Telemedicine offers numerous benefits for the military, other federal
and state government organizations, the private sector, and
individual patients because it eliminates distance as a factor in
treating patients.  Such benefits include access to care where it is
not otherwise available; improved quality of care; and, in many
instances, reduced costs.  However, costs could increase due to
investments in infrastructure and increased utilization of health
care services.  No comprehensive studies have been completed to prove
that telemedicine delivers cost-effective, quality care.  Early
efforts included few consultations and only provided anecdotal, or
retrospective, observations about the benefits.  Several federal
agencies and the private sector are beginning to implement some
comprehensive studies, but results from most of these studies will
not be known for several years. 


   TELEMEDICINE PROVIDES BENEFITS
   TO VARIOUS GROUPS
---------------------------------------------------------- Chapter 4:1

By eliminating distance as a factor in treating patients,
telemedicine benefits health care providers and patients, no matter
whether the setting is a military site, rural hospital, or
correctional facility.  Without telemedicine, persons who need
specialized care could be left untreated; improperly treated; or, if
time and circumstances permitted, transferred to another facility for
the care. 

Telemedicine provides benefits to the various groups by allowing
access to care where it is not otherwise available and improving the
quality of care delivered.  In addition, telemedicine may, in many
instances, reduce health care delivery costs. 


      TELEMEDICINE ALLOWS MORE
      ACCESS TO HEALTH CARE
-------------------------------------------------------- Chapter 4:1.1

For the medic on the battlefield, telemedicine provides immediate
access to a clinician with greater skills so that they can work
together to save a soldier's life.  DOD believes telemedicine could
reduce the mortality and morbidity rates on the battlefield by as
much as 30 to 50 percent.  Quality trauma care depends on the timely,
efficient, and accurate flow of information at each step of the
crisis management process.  Telemedicine can provide the vehicle for
this flow of information, which includes patient information,
treatment records, and medical knowledge. 

Telemedicine could provide a "bridge" for the 100,000 to 150,000
personnel deployed on military ships around the world who have
limited access to medical diagnostic and consultant services.  For
example, during a 6-month Western Pacific deployment in 1995, sailors
aboard the aircraft carrier U.S.S.  Abraham Lincoln had access to
enhanced specialist medical care from the Naval Medical Center in San
Diego, California, 6,000 miles away.  That access proved critical for
one sailor who injured his hand on a gun mount.  The injured sailor
was transferred from another ship to the Abraham Lincoln with the gun
mount part still implanted in his hand.  X-rays and video of his
injury were transmitted to San Diego where a specialist consulted
with the ship's surgeon to treat the injury.  The sailor returned to
light duty on his ship 3 days later.  Another case involved a sailor
aboard the U.S.S.  Enterprise who sustained a neck injury on the
flight deck.  Immediate telemedicine consultation was able to rule
out a cervical fracture. 

For peacetime military health care, telemedicine allows remote
military treatment facilities to link up with DOD medical clinics to
obtain specialized health care.  Similarly, telemedicine allows rural
communities to communicate with larger medical facilities to obtain
specialized care.  For example, a physician in remote Montana can
send a trauma victim's x-rays to a large hospital in Seattle, where a
radiologist can confirm that the patient has a broken vertebra and
needs to be evacuated immediately. 

The states and private sector can also benefit from improved access
to health care.  For example, an emergency medical technician on an
ambulance call or at a disaster site can use telemedicine to provide
immediate access to an emergency room physician who has greater
knowledge and can provide guidance to the technician to perform
skilled procedures to save an individual's life or limbs.  Improved
access to health care is especially important to patients in remote
areas.  For example, the University of Washington's telemedicine
network serves four communities in remote locations in the states of
Washington, Alaska, Montana, and Idaho.  Each site is located in an
area with rugged terrain and extreme cold weather, which can make
travel extremely dangerous or impossible. 

In addition, the Georgia Statewide Academic and Medical System is
dispersed among 60 health care facilities to ensure that all state
residents have immediate access to quality health care.  Many of the
state's large, poor rural populations may lack adequate access to
health care without traveling long distances.  Of the state's 159
counties, 9 have no physician, 85 have no pediatrician, and 140 have
no child psychiatrist. 

Finally, telemedicine may allow physicians to provide medical care to
patients in their homes.  For example, VA's Eastern and Western
Cardiac Pacemaker Surveillance Centers routinely use standard
telephone lines to monitor the electrocardiograms of pacemaker
patients from their homes.  A 1996 VA testimony indicated that the
surveillance centers save time and effort, provide pacemaker
expertise to remote and underserved areas, and decrease the need for
pacemaker clinic appointments.  In addition, pacemaker monitoring
improves health care quality and is convenient for veterans, since
they can be monitored 24 hours a day from any place that has a
telephone.  VA estimates it has made over 386,000 "house calls" from
1982 to 1996, or about 2,300 a month, using this system. 

In another effort, the Army's Center for Total Access at Eisenhower
Army Medical Center joined the Medical College of Georgia, the
Georgia Institute of Technology, and a local cable company to develop
a telemedicine home health care network, known as Electronic
Housecall.  This program, which became operational in February 1996,
links a nursing home and the homes of 25 chronically ill patients
with their health care providers.  Through daily monitoring, the
health care practitioners should be able to detect early changes in
the patients' condition.  If practitioners find changes, they can
prescribe a different treatment or request that patients come in and
see their physician.  By detecting problems earlier, hospital stays
may be avoided or reduced.  Each patient selected for this project
was chronically ill and averaged six or more hospitalizations per
year at an average cost per hospital stay of about $25,000. 


      TELEMEDICINE CAN IMPROVE
      HEALTH CARE QUALITY
-------------------------------------------------------- Chapter 4:1.2

Telemedicine gives health care providers a chance to enhance their
skills and expand their professional knowledge by linking providers
with experts.  In remote locations, health care is provided by
general practitioners.  When the practitioner believes a patient
needs specialized care, the practitioner frequently has to refer the
patient to a specialist in a different location and may not be
present in the consultation between the patient and the specialist. 
With telemedicine, the general practitioner is present during the
consultation and can learn from the specialist.  Telemedicine
advocates expect that such experiences will increase a practitioner's
medical knowledge, which in the future may help the practitioner to
diagnose and treat illnesses earlier or determine that the patient
needs to see a specialist right away. 

Enhanced knowledge would have been helpful to general practitioners
and medics during the Vietnam War.  According to an Army
dermatologist, if telemedicine had been used during the war, the
number of hospitalizations, evacuations, and days lost due to skin
diseases could have been reduced by about one-third.  Skin disease
was the primary reason for outpatient visits to Army medical
facilities during the war.  Between 1968 and 1969, skin diseases
accounted for 47 percent of total days lost for the U.S.  9th
Infantry Division.  According to the dermatologist, if the general
practitioners and the medics at the forward facilities had been able
to consult with skin specialists via telemedicine, they would have
learned to recognize and treat skin diseases earlier. 

Telemedicine also has the ability to deliver continuing medical
education to deployed medical units and remote health care
practitioners so that they have the opportunity to enhance their
professional knowledge without having to travel.  For example,
medical units in Bosnia received weekly continuing education classes
via telemedicine from a DOD medical center in the United States.  Two
of the classes covered acute care of burn victims.  One week after
the classes, two soldiers in Bosnia were severely burned in an
explosion.  The medical unit used what it had learned in the classes
to stabilize and treat the soldiers until they could be transferred
to a facility with more skilled care.  According to medical unit
personnel, without the classes the soldiers would not have received
the same quality of care at the site. 

The Medical College of Georgia offers one continuing professional
education credit for the referring health care practitioner
participating in telemedicine consultations.  The University of
Washington's School of Medicine is the only medical school directly
serving the states of Washington, Alaska, Montana, Idaho, and
Wyoming.  The medical school operates a medical education program via
a telecommunications network to affiliate teaching facilities in
these states.  In California, a health maintenance organization
provides continuing medical education over its telecommunications
networks.  One of the organization's programs delivers monthly
lunch-hour medical education classes that reach about 1,000 of its
3,500 physicians. 


      MANY EXAMPLES IDENTIFY COST
      SAVINGS
-------------------------------------------------------- Chapter 4:1.3

An Arthur D.  Little Foundation study published in 1992 on the U.S. 
health care crisis said that just the video conferencing component of
telemedicine used for remote medical consultations and professional
training could reduce health care costs annually by over $200
million.  For example, video consultations can shorten diagnostic
time, reduce treatment time, and decrease hospital stays. 
Telemedicine can also reduce evacuation or travel costs incurred when
patients and specialists have to travel for consultations. 

Several service officials believe that telemedicine's biggest cost
benefit to DOD will be its application to the reengineering of health
care delivery during peacetime.  In fiscal year 1997, MHSS' budget is
over $15 billion and includes 115 hospitals and 471 medical and
dental clinics operating worldwide. 

In a case involving 12 patients over a 4-month trial period,
Eisenhower Army Medical Center's critical care telemedicine project
with Fort Stewart's hospital saved DOD at least $54,000 in
transportation costs and expenses associated with the Civilian Health
and Medical Program of the Uniformed Services.  Two patients did not
need to be transferred to Eisenhower or the local hospital, and one
patient's stay at a non-DOD hospital was shortened.  Teleradiology
used on a 4-month deployment of the U.S.S.  George Washington in the
Mediterranean Sea and Indian Ocean eliminated the need for 30
evacuations and saved about $100,000.  Telemedicine also saved DOD
$63,000 in evacuation costs during its deployment to Somalia. 

Telemedicine can provide cost savings to states in prison health care
transportation costs.  For example, since Georgia began using
telemedicine in its prisons in 1993, only about 25 percent of the
prisoners seen via telemedicine had to be transferred to another
facility for further treatment.  In the first 10 months of 1995, 218
consultations were done, saving between $82,000 and $246,000 in
transportation costs for those consultations that did not result in a
transfer to another facility.  In Texas, the Department of Criminal
Justice contracts with the University of Texas Medical Branch at
Galveston and Texas Tech Health Sciences Center to provide health
care to its inmates in correctional facilities.  In the first 20
months of operation, 2,607 telemedicine consultations were conducted
with high patient satisfaction.  An evaluation showed that about 96
percent of the consultations saved at least one trip to the Galveston
Medical Center at an estimated cost of about $190 per trip, or about
$495,000. 

Telemedicine can also provide savings in hospital costs.  Initial
data from the Medical College of Georgia showed that over 80 percent
of patients seen via telemedicine did not need to be transferred from
their primary medical facility to a specialized care facility.  Given
the cost difference of between $500 and $740 per day per bed between
rural hospitals and the Medical College of Georgia, cost savings
resulting from telemedicine may be significant.  In Minnesota, a
managed health care company and a rural health care company formed a
partnership to develop a rural telemedicine network.  As part of this
network, eight rural hospitals were connected to a larger community
hospital for emergency room consultations.  Early indications have
pointed to overall cost savings for the participating facilities. 
For example, one referring rural hospital was able to decrease its
emergency room operating costs by $47,500 a year, even after paying
an additional $50,000 fee to the community hospital for
consultations.  Due to the increased referrals from the eight rural
hospitals and the yearly fees, the community hospital was able to
eliminate its yearly $300,000 emergency room operating deficit. 

In addition, because telemedicine brings specialized health care to
the patient, the patient does not need to take as much time away from
work or duty to receive care.  This results in increased productivity
for the worker and the employer and fewer lost wages.  In DOD's case,
reducing the time away from work results in increased readiness of
its military forces.  For example, Tingay Dental Clinic at Fort
Gordon, Georgia, used telemedicine to provide specialized dental
consultations to active duty personnel at Forts McPherson and
Benning, Georgia; Fort McClellen, Alabama; Soto Cano Air Force Base,
Honduras; Gorgas Army Hospital, Panama; and the Naval Dental
Detachment, Key West, Florida.  Without these consultations, the
soldiers would have to take time away from duty and travel for
specialized dental care.  A study done by the clinic showed that
soldiers at Fort McPherson saved at least one-half day away from duty
for each consultation. 

A telemedicine project at Fort Jackson, South Carolina, decreased the
amount of time a soldier missed basic training.  Typically, a soldier
on sick call would lose a whole day of training because of the time
to drive to the clinic, wait to see the physician, get a prescription
filled, and return to the field.  Of 101 soldiers seen via
telemedicine, about 20 percent returned to training without going to
the clinic.  DOD officials believe that as the practitioners get more
familiar with the equipment and the medical procedures are
streamlined, more than 50 percent of the soldiers will be able to
return to training without going to the clinic. 


   POTENTIAL SAVINGS MAY BE OFFSET
   BY INFRASTRUCTURE COSTS AND
   INCREASED USE
---------------------------------------------------------- Chapter 4:2

Although some data show that telemedicine can save costs, other data
indicate that there is a high cost for using telemedicine both in
total dollars and per consultation.  Main factors include
infrastructure start-up costs and operational costs of the systems
and equipment.  For example, the infrastructure start-up, equipment,
and operational costs for DOD's telemedicine deployment to Bosnia are
estimated to total about $30 million, and only about 60
consultations, excluding teleradiology cases, have been performed to
date.  Also, recurring basic telemedicine line charges in rural
communities can run about $1,500 a month.  Various officials
expressed concern whether the volume of rural telemedicine
consultations can ever be high enough to pay the recurring line
charges as well as initial equipment expenditures. 

Another factor that will affect the cost of telemedicine is increased
utilization by persons who previously did not have access to such
care.  According to the Institute of Medicine's report on
telemedicine, home monitoring via telemedicine may result in earlier
identification and treatment of problems that would be more costly to
treat if not caught early, but it may also identify more borderline
problems that would generate more home or office visits.\1

The potential cost impact of inappropriate utilization of health
services via telemedicine is a concern for many third-party payers,
such a Medicare.  These concerns are not as apparent in managed
health care settings, including DOD and VA, where many costs are
fixed, including physician salaries.  On the other hand,
fee-for-service providers receive their income from the volume and
type of services provided.  In such settings, some providers may use
complex and costly medical technologies when less costly techniques
may suffice. 

Without a payment support mechanism, infrastructure or health care
providers may not consider telemedicine alone to be capable of
delivering a sufficient return to justify their investment.  However,
if multiple applications are available to use the infrastructure,
such as those related to business, education, or entertainment, the
infrastructure cost can be shared among the various users. 

Officials at the Health Care Financing Administration (HCFA) are also
concerned that Medicare expenditures could significantly increase if
Medicare were to begin reimbursing for telemedicine consultations. 
Various reports have cited an estimate that telemedicine
consultations could increase the total Medicare budget by $30 billion
to $40 billion annually by the year 2000.  Our review found no
evidence to support this increase.  HCFA officials indicated that the
agency could not estimate what the impact would be to the Medicare
budget if the federal government began reimbursing for telemedicine
consultations, but the amount should be much less than the $30
billion to $40 billion increase cited by various reports. 


--------------------
\1 Telemedicine:  A Guide to Assessing Telecommunications in Health
Care, Institute of Medicine, 1996. 


   COST-EFFECTIVENESS OF
   TELEMEDICINE HAS NOT BEEN
   ANALYZED
---------------------------------------------------------- Chapter 4:3

Although many individuals strongly believe that telemedicine is a
good value, no one has quantified the benefits through a
comprehensive cost-benefit analysis.  Evidence supporting these
beliefs is mainly based on anecdotal examples, small retrospective
reviews, or personal opinions.  In fact, the lack of comprehensive
evaluations was a major theme throughout the 1996 American
Telemedicine Association Conference.  In the past, such studies have
not been done because adequate sample sizes were not available or the
financial resources for conducting the evaluations were lacking. 
However, several agencies are now funding or conducting comprehensive
studies. 


      EARLY STUDIES FOCUSED
      PRIMARILY ON TECHNICAL
      FEASIBILITY
-------------------------------------------------------- Chapter 4:3.1

Early telemedicine programs concentrated on demonstrating that the
technology would enable the health care practitioner to diagnose and
treat patients at remote sites.  The primary focus was on whether the
technology worked, and cost-benefit analyses were not built into
these early projects. 

Despite 12 telemedicine deployments since 1993, DOD's only documented
studies appear in three articles in professional journals.  DOD has
compiled some lessons learned from Army deployments, the Advanced
Warfighter Experiments, and Joint Warfighter Interoperability
Demonstrations.  These studies, however, had a limited scope and
raised additional questions. 

A 1996 Army study on telemedicine deployments showed that
telemedicine significantly changed the diagnosis in 30 percent of the
cases seen and the treatment in 32 percent of the cases.  However,
the study noted that because of limitations, such as lack of
follow-up and outcome data, response time, and user satisfaction, the
data may provide limited results.  Additionally, the exclusion of
incomplete records may have also skewed the results.  For example,
the use of telemedicine may have precluded air evacuations, but there
was little or no information on whether the patient had a worse
outcome or needed evacuation after the consultation.  Because of the
lack of a central records system, it was impossible to follow
individual cases to determine case outcomes. 

This study also noted that the types of patients seen in operations
other than war differ from those seen in active combat, suggesting
that the results may not be indicative of the benefits of battlefield
telemedicine.  For example, combat support hospitals are staffed to
treat previously healthy young soldiers suffering from trauma and are
not configured for pediatric patients and chronic infectious disease
cases.  The study concluded that further analysis may help determine
if a combat support hospital in an operation other than war needs
modification.  It also suggested that the large number of dermatology
consultations may indicate that dermatologists should routinely
deploy with combat support hospitals. 

During its Advanced Warfighter Experiments in 1994 and 1996, the Army
Medical Department demonstrated that medics using lightweight,
hands-free, two-way radios were able to communicate with medical
officers at battalion aid stations to provide lifesaving medical
treatment.  This communication impacted the number of soldiers who
may have never been evacuated off the battlefield.  However, few
trends become apparent from analyzing the data from the different
experiments.  Some data showed that medics utilized the consultations
more if the number of casualties was small.  As the number of
casualties increased, consultations went down.  Because the time
required to treat each casualty increased, other wounded could die
while the medic was in a consultation.  The Joint Warfighter
Interoperability Demonstrations showed that the different services'
medical communication systems were incompatible with each other and
the warfighter. 

Early rural health demonstrations have also provided some lessons
learned about network structure, personnel, funding, and equipment
considerations when establishing telemedicine networks.  For example,
HHS' Office of Rural Health Policy (ORHP) compiled results and
preliminary lessons learned from 1995--the first year of experience
of 11 of its 25 telemedicine grantees--but it is too early to know
whether these projects will be successful in improving access to care
for rural residents.  It is also unclear how the projects will affect
the multispecialty hospitals, rural hospitals, and clinics that are
part of these networks.  Further, an ORHP internal study reported
that developing a telemedicine network is complex, requiring
coordination and cooperation from multiple players both within and
outside the health care arena. 


      DOD TELEMEDICINE EVALUATIONS
      ARE NOT COORDINATED AMONG
      SERVICES OR FACILITIES
-------------------------------------------------------- Chapter 4:3.2

A number of DOD organizations are planning and implementing
telemedicine evaluations.  However, there is little coordination
among the sites in developing these evaluations.  In addition, the
evaluations may not be used outside each organization to develop a
DOD-wide database or collective evaluation to provide DOD
policymakers with data they can use to establish a DOD strategic plan
or prioritize funding. 

Some TRICARE regions are planning to evaluate telemedicine costs and
benefits.  Tripler Regional Medical Center in Hawaii allocated
$700,000 to fund an evaluation of its telemedicine initiatives.  The
evaluation will address (1) clinical outcomes, (2) patient and
provider satisfaction, (3) costs and benefits, (4) human behavior
factors such as personnel and training, and (5) organizational
impact.  According to officials, the telemedicine protocols and
evaluation tool were developed without coordination with other
TRICARE regions, although they were shared among DOD agencies during
an August 1995 workshop in Hawaii on telemedicine evaluation
methodologies. 

Two separate evaluations are planned for Madigan Army Medical
Center's teleradiology and telemedicine systems.  The teleradiology
evaluation, being developed and conducted by a Department of Energy
contractor, will address the impact of the Medical Diagnostic Imaging
Support/teleradiology on radiology operations, procedures, costs, and
patient satisfaction. 

The evaluation of other telemedicine systems will identify (1) the
impact of telemedicine procedures on the costs of collecting clinical
information for consultations conducted at the military treatment
facilities and VA's Puget Sound Healthcare System and (2) the
correlations of user and service characteristics to clinical
information acquisition costs of telemedicine procedures.  The study
will result in lessons learned and a proposed methodology for future
projects.  VA's medical center in Seattle is developing the study,
which will be tested at all DOD and VA facilities in the Puget Sound
area.  The VA official responsible for developing the evaluation said
that she has not received any input or assistance from DOD personnel,
except for Madigan Army Medical officials. 

The Center for Total Access plans to evaluate its telecardiology
program once it is operational.  Center personnel are working with a
MATMO contractor that is developing software, including cardiac
protocols or standardized procedures.  The Center's director was
unaware that a project at Tripler Regional Medical Center had already
developed cardiac protocols. 

Wilford Hall Air Force Medical Center in San Antonio is planning to
conduct a cost-benefit analysis of some of its telemedicine efforts. 
A goal of the analysis is to compare average costs per consultation
for certain specialties with and without telemedicine.  The project
will gather information on referral patterns to the specialties and
sites.  This information will then be used to calculate an average
cost to the government per consultation by site and specialty.  The
study will examine both active and non-active duty patients. 
Officials have not developed an approach to coordinate the evaluation
with other TRICARE regions. 


      CIVILIAN AGENCIES ARE
      CONDUCTING WIDE-REACHING
      EVALUATIONS
-------------------------------------------------------- Chapter 4:3.3

Other federal agencies that are now funding or conducting
large-scale, comprehensive evaluations of telemedicine include VA,
the National Library of Medicine, HCFA, ORHP, and the Agency for
Health Care Policy and Research.  However, these evaluations are in
the early stages and frequently have not been coordinated among or
within agencies. 

Several civilian agencies have recently required their grantees and
contractors to perform evaluations as part of their projects. 
Because most of these projects have not reached completion,
evaluation results have not been reported.  Some of these evaluations
examine broad issues, and some will have a limited focus.  For
example, each HCFA telemedicine payment demonstration grantee in
Iowa, Georgia, North Carolina, and West Virginia is evaluating the
costs and benefits of reimbursing specialists for providing medical
services via telemedicine to Medicare patients. 

Eleven of ORHP's 25 telemedicine grantees will evaluate the relative
effectiveness of their telemedicine project in a rural environment
and identify barriers to effective implementation.  Similarly, one
project involving six rural Texas communities, funded by the Agency
for Health Care Policy and Research, includes an analysis of the
factors that facilitate or hinder the long-range commitment to
telemedicine use for interactive video and continuing education. 

Each of the 22 contractors involved in the National Library of
Medicine's High Performance Computing and Communications Program will
evaluate the impact telemedicine can have on health care access,
quality, and cost.  For example, a hospital in Boston will use
telemedicine to provide educational and emotional support to families
of high-risk newborns both during their hospitalization and following
discharge.  The program will examine the potential of telemedicine to
decrease the cost of care for infants with very low birth weights by
increasing the efficiency of care. 

A number of federal civilian agencies are working with the private
sector to conduct comprehensive evaluations of telemedicine.  For
example, in fiscal year 1996, ORHP awarded $200,000 for the
Telemedicine Research Center of Portland, Oregon, to develop a
standard data set for telemedicine evaluation and conduct an
objective and scientific evaluation of telemedicine programs.  The
project will last 2 years and cost $330,000.  The purpose of the
project is to collect basic information about the operations,
utilization, costs, benefits, and sustainability of the rural
telemedicine projects that ORHP funds.  This report is expected to be
issued in 1998. 

The evaluations will also develop an evaluation methodology rather
than assess the success of a specific telemedicine project.  For
example, an Institute of Medicine study, titled "A Guide to Assessing
Telecommunications in Health Care," develops a framework for
evaluating telemedicine's effects on the quality, accessibility,
costs, and acceptability of health care compared with alternative
health services.  The framework includes strategies or questions that
could be used by anyone planning to perform an evaluation.  One
question is whether a teledermatology consultation provides the same
quality of patient care and therefore the same outcome as a
face-to-face consultation.  Another question is whether the
teleconsultation result provides more timely access to the
dermatologist than a scheduled face-to-face consultation.  Officials
hope that this framework will standardize evaluations enough to
promote comparability so that the results from individual studies can
be combined to provide the evidence needed to quantify the benefits
of telemedicine. 

JWGT also developed a discussion paper outlining a broad evaluation
framework for telemedicine.  The goal of this paper was to provide a
document for an entity to design its own evaluation to meet its needs
but at the same time be comparable to other studies.  The Puget Sound
VA evaluation will closely follow JWGT's evaluation framework paper. 

Other evaluations will be follow-up or more comprehensive views of
specific grants that had required their own evaluations.  For
example, ORHP sponsored a study by Abt Associates to estimate the use
of telemedicine in rural hospitals and identify and describe those
rural hospitals that are actively involved in telemedicine.  The
initial screening survey generated valuable information about the
extent of telemedicine use in rural communities, but it also raised
many new questions that must be addressed through a detailed
follow-up survey.  The final report, which included an in-depth
follow-up survey, was issued in December 1996.  Among other issues,
the report addressed utilization, technologies employed,
infrastructure costs, and accessibility. 

In another case, HCFA has signed a cooperative agreement with the
Center for Health Policy Research at the University of Colorado to
evaluate the effects of teleconsultation payments on access to
services and quality of care for the five telemedicine projects HCFA
supports.  Under these projects HCFA will experiment with alternate
payment schemes, including separate payments to providers at each end
of the network as well as a single "bundled" payment to cover both
providers.  The center will collect information about diagnoses,
health service utilization, patient and provider satisfaction,
quality of care, and patient outcomes.  This report is expected to be
issued in early 2000. 


SEVERAL BARRIERS LIMIT
TELEMEDICINE ACTIVITIES
============================================================ Chapter 5

Several barriers, in addition to the lack of project evaluation,
prevent patients and providers from realizing widespread benefits of
telemedicine.  Experts in telemedicine generally agree that these
barriers can be primarily categorized as legal and regulatory,
financial, technical, and cultural.\1 Legal and regulatory barriers
involve such issues as interstate licensing, malpractice liability,
privacy and security, and regulation of medical devices.  Financial
barriers relate to reimbursement of providers and high infrastructure
costs.  Technical barriers are created by lack of standards and
equipment incompatibility.  Cultural barriers involve physician and
patient acceptance.  Most U.S.  telemedicine networks that are not
limited to teleradiology enjoy some financial support from federal
grants and contracts for limited periods.  Unless these networks can
overcome telemedicine barriers, their sustainability is jeopardized
once federal support lapses. 


--------------------
\1 Telemedicine literature, reports, interviews with selected federal
agencies, national medical specialty groups, and other organizations
provided an in-depth review of the key barriers and validated their
impact on the implementation of telemedicine. 


   BARRIERS HAMPER THE PRIVATE
   SECTOR MORE THAN THE FEDERAL
   SECTOR
---------------------------------------------------------- Chapter 5:1

The private sector, particularly fee-for-service providers, is
generally affected by all barriers--legal and regulatory, financial,
technical, and cultural.  Federal sector agencies that directly
deliver health care services, such as VA and DOD, are less affected
than the private sector by legal and regulatory barriers, but
cultural (particularly physician acceptance) and technical barriers
hinder both sectors' development of telemedicine.  However, VA has an
extensive telecommunications system that is available for health care
applications.  As a result, DOD, the Indian Health Service (IHS),
BOP, and VA may be better positioned to advance the development of
telemedicine.  Figure 5.1 shows the segments that are affected by
each of the barriers we have identified.  Many groups and
organizations in the public and private sectors are working
individually and as partners to develop strategies and options for
overcoming barriers to telemedicine. 



                                    Table 5.1
                     
                     Specific Telemedicine Barriers Impacting
                      Government and Private Sector Entities

                                    Government                Private sector
                          ------------------------------  ----------------------
                                                             Managed     Fee for
Barrier                      DOD      VA     IHS     BOP        care     service
------------------------  ------  ------  ------  ------  ----------  ----------
Legal and regulatory
--------------------------------------------------------------------------------
Licensure                                                          X           X
Malpractice liability                                            X\a           X
Privacy and security           X       X       X       X           X           X
Regulation of medical          X       X       X       X           X           X
 devices

Financial
--------------------------------------------------------------------------------
Lack of reimbursement                                                          X
High infrastructure            X               X       X           X           X
 costs

Technical
--------------------------------------------------------------------------------
Lack of standards              X       X       X       X           X           X
Technology performance
 and equipment                 X       X       X       X           X           X
 compatibility

Cultural
--------------------------------------------------------------------------------
Physician acceptance           X       X       X       X           X           X
Patient acceptance            \b      \b      \b      \b          \b          \b
--------------------------------------------------------------------------------
\a A managed care organization may be exposed to additional
malpractice liability suits when its patients or health care
providers consult via telemedicine with physicians outside the
organization. 

\b The extent of the problems presented by this barrier is unknown. 


   LEGAL AND REGULATORY BARRIERS
---------------------------------------------------------- Chapter 5:2

Legal and regulatory barriers to implementing telemedicine activities
are licensure issues, malpractice liability, privacy and security,
and regulation of medical devices.  These barriers will require
federal, state, and private efforts to solve them.  Federal and state
health policymakers and working groups representing federal and
private sector interests (including national organizations and
companies) are working individually and collectively on approaches
for overcoming these barriers.  As a focal point, JWGT is conducting
an in-depth review of legal and regulatory barriers, among others, to
gain a clearer understanding of the impediments that hinder the
advancement of telemedicine. 


      REQUIREMENTS FOR MULTIPLE
      MEDICAL LICENSES
-------------------------------------------------------- Chapter 5:2.1

According to individuals we contacted and literature we reviewed, one
of the major legal barriers encompasses the licensure of health care
professionals providing telemedicine services in multiple states.  In
the United States, physicians must be licensed in each state in which
they practice medicine to protect the health, safety, and welfare of
the public.  One issue facing many states is whether a physician who
provides medical advice to someone in another state via telemedicine
is in effect practicing medicine in the patient's state.  Another
issue is that obtaining and maintaining licenses in other states can
be a time-consuming and expensive effort. 

For physicians who regularly or frequently engage in the practice of
medicine across state lines, the Federation of State Medical Boards
of the United States, a private organization, developed a model act
in April 1996 that would create a special license for physicians to
practice telemedicine in a state where they are not currently
licensed.  If the model act is adopted by states, this special
license could remove the need for physicians to obtain a full license
in each state where they practice telemedicine.  Physicians who
merely consult with other physicians in certain states concerning
medical diagnosis and treatment, however, are less likely to
encounter licensing barriers than physicians having direct and
frequent contact with patients in other states.  In opposition to the
model act, various national associations, such as the American
Medical Association, recommended full and unrestricted licensure by
individual states for physicians who wish to practice telemedicine
across state lines.  In contrast, the National State Board of Nursing
has recommended one national license instead of numerous state
special licenses. 

Our review of literature and other reports revealed that some states
are beginning to restrict medical practice through telemedicine.  At
least 12 states have taken specific action regarding licensure of
out-of-state physicians.  Of the 12 states, 10 require out-of-state
physicians to be licensed in their states.  In the 11th state,
Florida, out-of-state physicians who conduct telemedicine services do
not need a Florida license as long as the physician who ordered
medical services is authorized to practice medicine in Florida.  In
the 12th state, California, the state's medical board is authorized
to establish a registration program that would permit a practitioner
located outside the state to practice in the state upon registration
with the board. 

Licensing is generally not a barrier for federal agencies.  Federally
employed physicians who treat patients in government facilities are
required to be licensed in only one state, which does not have to be
the one in which they are practicing.  However, if a federal
physician treats a patient not eligible for federal benefits, the
physician is required to have a license in the patient's state. 
Similarly, licensing would apply if, for example, a VA hospital
joined a telemedicine network that included private hospitals and VA
physicians were required to see private patients.  This licensing
requirement would generally apply to all federal physicians. 


      MALPRACTICE LIABILITY
-------------------------------------------------------- Chapter 5:2.2

Malpractice exposure is always present in a doctor-patient
relationship.  The risk of additional malpractice liability
constitutes another barrier to the practice of telemedicine in the
private sector, particularly in networks that cross state lines. 
There is uncertainty whether a physician who uses telemedicine to
"see" a patient in another state will be subjected to the
jurisdiction of the courts in the patient's state. 

Fundamental issues regarding telemedicine encounters remain vague. 
In its March 1996 report, the Council on Competitiveness noted that
the issue of malpractice is perhaps the greatest unknown barrier.\2
The Council believes that a key question is whether a distant
physician who performs a telemedicine consultation will be held
subject to the jurisdiction of the courts in the patient's judicial
district.  It is unclear under what circumstances a remote encounter
via telemedicine could subject a practitioner to malpractice
litigation in the remote state.  For example, one report suggests
that the risk of malpractice is heightened when the practitioner is
in one location and the patient, in another location, is in the
presence of only a nurse or physician's assistant.  Even when
physicians are at both ends of the telemedicine transmission, the
specialist who guides or supervises the less skilled physician
performing the procedure could be sued in a distant court for
malpractice. 

Given this uncertainty and the relatively little guidance that the
small number of lawsuits throughout the country can offer, the
malpractice insurance industry is still considering whether the
expansion of telemedicine requires a change in coverage to
specifically include telemedicine in rating bases.  Thus, if an
individual physician believed his or her malpractice coverage was not
sufficiently comprehensive to include the many facets of
telemedicine, that practitioner's willingness to engage in
telemedicine could pose a barrier. 

These concerns are also expressed by the American Medical
Association, which believes that the law is currently unclear where
liability falls when two or more practitioners cooperate on a medical
problem using telemedicine.  One representative of an association of
physician-owned malpractice insurance companies told us that she was
aware of only four malpractice suits concerning telemedicine (all of
which were settled out of court), but she believed that others might
reach the courts soon because of the length of time for a case to
come to trial. 

Medical malpractice issues in the federal sector differ from the
private sector.  In the federal sector, the controlling law is the
Federal Tort Claims Act (FTCA),\3 which for more than 40 years "has
been the legal mechanism for compensating persons injured by
negligent or wrongful acts of Federal employees committed within the
scope of their employment."\4 FTCA provides that a suit against the
United States for a wrongful act or omission by a federal employee or
officer shall be the exclusive remedy permitted to a claimant and
that no federal employee can be sued.  Additionally, parallel
provisions pertaining to VA, DOD, and HHS expressly state that
malpractice and negligence suits against medical personnel of those
agencies are barred and that the exclusive remedy is an action
against the United States.  Therefore, even though telemedicine is a
potential cost to the government, the threat of malpractice suits
against individual federal physicians is not a barrier. 

The protections of FTCA generally extend only to federal employees
and officers acting within the scope of their employment and
authority.  The protections generally do not apply to a contractor of
the United States.  To date, no suits have been filed against the
federal government involving telemedicine.  Such suits, which are
decided according to the law of the jurisdiction where the act or
omission occurred, may help determine the scope of liability of the
federal government for the practice of medicine. 

In the private sector, medical malpractice suits may be vulnerable to
"venue shopping," under which a patient can elect to bring suit
against a practitioner in any state where that practitioner does
business, regardless of where the act or omission occurred.  A
physician or institution that practices medicine in multiple states
could be sued, therefore, in the state where jury awards are most
favorable, even if the particular telemedicine consult being sued
upon occurred elsewhere. 


--------------------
\2 Highway to Health:  Transforming U.S.  Health Care in the
Information Age, Council on Competitiveness, March 1996. 

\3 28 U.S.C.  Sections 2671 and 2679. 

\4 28 U.S.C.  Section 2671 note. 


      PRIVACY AND SECURITY OF
      MEDICAL DATA
-------------------------------------------------------- Chapter 5:2.3

Another barrier to widespread deployment of telemedicine applications
and computer-based patient record systems is the public's concern
that the privacy and security of personally identifiable medical data
will be jeopardized.  One example that underscores concerns over the
handling of medical records involved the leak of a confidential list
of Pinellas County, Florida, residents with AIDS (Acquired Immune
Deficiency Syndrome).  The release of this list, which was on
computer disc and had close to
4,000 names, revived concern about the proper handling of sensitive
medical records. 

Among many federal agencies, there is strong interest in the
development and use of computer-based patient record systems and
other transmission of medical data via telecommunications networks in
support of patient care, clinical research, health services research,
and public health.  An integrated information system (1) allows
medical providers to have access to a patient's medical record, even
if the paper record is not available, and quickly assembles patient
information from multiple sources (x-rays, pharmacy, and lab).  Once
this information is assembled, provider organizations, practitioners,
payers, and the public sector would be able to move critical
information among themselves.  Such exchanges may enhance the ability
of providers to render services across the continuum of care, reduce
duplication, and improve the quality of care. 

The benefits of an integrated information system come with risks.  A
1995 report from the Physicians Payment Review Commission
acknowledged that the benefits of data integration capabilities
offered by telemedicine systems are accompanied by risks of violating
a patient's right to privacy.\5 The report stated that patients' data
privacy rights should be protected by obtaining a patient's
permission before participating in teleconsultations, including
written agreement for recording of sessions and storage of tapes as
part of medical records.  Further, using data protection techniques
during transmission could prevent disclosure.  Even when patients are
properly informed about the transmission or electronic storage of
medical records, concern remains about the protection of such records
by telemedicine providers, including security for the computer
systems and other media on which they are stored. 

Several reports indicate an absence of state-to-state uniformity in
confidentiality and privacy laws that could have an adverse impact on
the transfer of medical data for use in telemedicine encounters.  One
study by the Office of Technology Assessment expressed concern that a
videotaped consultation that becomes part of a patient's medical
record would be treated as the state treats other videotaped
information on the patient.\6 Because state laws governing the
transmission and retrieval of patient medical records vary, officials
are concerned about user verification, access, authentication,
security, and data integrity. 

Efforts are underway to (1) identify the privacy-related issues that
arise particularly from the electronic environment of computerized
records and network information systems and (2) recommend policies to
address those issues.  In March 1995, the Vice President asked HHS to
lead efforts to develop model institutional privacy policies and
model state laws for health information in the context of the
National Information Infrastructure.  An interdepartmental working
group on privacy is currently identifying privacy issues related to
transmission of health information and other issues involving
electronic communications technology and integrated data systems. 
The group will make policy recommendation to address these issues. 
The results of their efforts are being discussed at JWGT meetings. 


--------------------
\5 Annual Report to Congress, Physicians Payment Review Commission,
1995. 

\6 Bringing Health Care Online:  The Role of Information
Technologies, Office of Technology Assessment, 1995. 


      SAFETY AND THE NEED FOR
      POLICY ON MEDICAL DEVICES
-------------------------------------------------------- Chapter 5:2.4

FDA has responsibility for ensuring that medical devices are safe and
effective and minimizing exposure from radiation-emitting electronic
products.  However, FDA has not clarified which telemedicine
components fall within its definition of medical devices.  Further,
some of FDA's policies are out-of-date, particularly for computer
software used in diagnosing patient conditions.  Some manufacturers
and others believe that these FDA policies and procedures have
limited marketing of new products. 

FDA's role has generated controversy in the telemedicine community. 
Some believe that telemedicine systems are medical devices in need of
FDA review.  Others believe that (1) these systems require FDA review
no more than a telephone or fax machine used to communicate
information used in patient diagnosis/treatment and (2) FDA
regulation of telemedicine equipment may be unwarranted.  In some
instances, FDA's review process for medical devices is complicated
and lengthy. 

FDA's basis for regulating certain software as medical devices is
contained in its 1987 draft guidance and a 1989 update.  According to
the Council on Competitiveness' March 1996 report, the review process
for medical devices--which would also guide review of certain types
of software--imposes an unworkable burden on software developers.  In
its July 1996 report to JWGT, FDA stated that major efforts are
underway to define and develop software policy.  The policy is
expected to clarify the factors that determine which types of
software are medical devices and the degree of regulatory scrutiny
required. 

As a first step in developing a policy, FDA conducted a forum in
September 1996 to address its role in regulating software for
clinical decision-making and proposed future directions related to
software distribution issues, risk categories, and notification
requirements.  Further FDA efforts will be subject to comment by
relevant public and private sector interests to ensure broad input
into future decisions.  As of November 1996, FDA had not yet revised
its policy. 


   FINANCIAL BARRIERS
---------------------------------------------------------- Chapter 5:3

The lack of reimbursement for consulting physicians' services and the
prohibitive high cost of telecommunication transmission services have
deterred the expansion of telemedicine.  Without good management
plans to ensure future sources of funds, some telemedicine networks
may not be sustained after federal funding subsidies lapse. 


      NO MEDICARE REIMBURSEMENT OF
      PROVIDERS
-------------------------------------------------------- Chapter 5:3.1

Currently, HCFA does not reimburse for telemedicine consultations for
Medicare patients.  One report indicated that HCFA's current position
is one of the major obstacles to telemedicine's current use and
future development.\7 Fee-for-service providers who treat Medicare
patients are affected by this obstacle, as well as those providers
who are paid by insurers that follow HCFA's lead when deciding what
costs to reimburse.  HCFA is concerned that reimbursing consultant
services via telemedicine could significantly increase expenditures
from Medicare trust funds, which are already facing threats to their
solvency. 

A HCFA official stated that Medicare does not pay for telemedicine
because it believes the standard practice of medicine requires an
"in-person, face-to-face consultation" between the patient and
practitioner for most medical specialties.  In contrast, HCFA pays
for telemedicine involving radiology and pathology because these
specialties do not typically require face-to-face contact with the
patient.  HCFA also notes that with the exception of the American
College of Radiology, the medical community has not developed
practice guidelines for telemedicine. 

In the area of Medicaid, a recent JWGT report indicates that at least
12 states now cover some aspect of telemedicine under Medicaid, and
other Medicaid programs are pursuing coverage.  Since Medicaid does
not mandate a face-to-face encounter, a waiver is not needed for
states to add telemedicine as an optional covered service. 

In October 1996, HCFA announced that it will begin limited Medicare
payments for telemedicine consultations in four states under a
demonstration project.  HCFA will evaluate those ongoing projects to
(1) demonstrate the effectiveness of rural telemedicine systems and
(2) develop, test, and evaluate payment methodologies for
telemedicine consultations.  Project evaluations are focused on the
effects of telemedicine systems on accessibility, quality, and cost
of health care.  However, HCFA reports that until the analyses of the
demonstration projects are completed, Medicare will not reimburse for
video consults beyond the demonstration projects.  Without proper
research results and guidelines, HCFA, as well as other insurers, are
concerned that reimbursement for these services will further increase
the cost of medical services. 

An official from a managed care organization agrees with HCFA's
concern that increased access may result in increased utilization and
thus increased cost.  However, that official believes that expanded
use of capitated managed care systems will enhance the appeal of
telemedicine and reduce the need for HCFA reimbursement. 


--------------------
\7 Rashid Bashshur, Dena Puskin, and John Silva.  "Telemedicine and
the National Information Infrastructure." Telemedicine Journal, Vol. 
1, No.  4 (1995), p.  359. 


      HIGH INFRASTRUCTURE COSTS
-------------------------------------------------------- Chapter 5:3.2

Another frequently cited barrier to implementing telemedicine is lack
of infrastructure in rural areas due to the prohibitive cost of
running fiber optics or providing satellite, T-1, or Integrated
Services Digital Network transmission service to a small end-user
population.  According to a 1995 HHS report, supporting the high
fixed costs of maintaining a telecommunications infrastructure is
clearly beyond the capability of small hospitals, particularly
without subsidies or cost-sharing arrangements among multiple
users.\8 Small disparate rural telemedicine networks and other users
do not have sufficient market power to negotiate favorable rates and
service from telecommunications providers. 

Some states, including Texas, have intervened and directed utility
companies to limit charges to nonprofit health and education
organizations.  An official of one network told us that, after state
intervention, the long distance carrier reduced its monthly charge
for T-1 lines from $2,500 to $250 a month. 

Our Georgia case study revealed that officials were concerned about
the high costs of recurring line charges.  VA, DOD, state, and
private sector officials told us their recurring line charges ranged
from $1,100 to $1,500 a month.  In Georgia, the state temporarily
subsidized line charges for remote sites on the state network.  Some
public officials, as well as private organizations within the state,
worry that some smaller rural communities might have to close their
centers once state funding is exhausted because they may not be able
to afford the recurring monthly communication charge. 

Universal service and advanced telecommunications service provisions
of the Telecommunications Act of 1996 are intended to reduce costs in
two ways.  First, it will promote competition among local access and
long-distance providers to make the National Information
Infrastructure affordable and widespread.  Therefore, a larger array
of services may be available to select from at competitive prices. 
Second, the act will require utility companies to equalize rates
between urban and rural users.  Strategic partnerships between the
health care industry and infrastructure providers may also speed the
development of advanced telemedicine systems.  The Federal
Communications Commission is implementing these provisions of the act
but has not made official recommendations in this area. 

Local end users need a continuing source of revenue to support
telemedicine programs once demonstration grant funds have lapsed, and
some supporting programs have addressed that need.  For example, the
Department of Agriculture's Distance Learning and Medical Link Grant
Program requires applicants to demonstrate local financial support by
providing evidence that their projects will be self-sustaining.  The
Institute of Medicine's 1996 report acknowledges that few projects
appeared to be guided by a business plan or the project features and
results necessary for a sustainable program.\9 In contrast, federal
agencies are not required to earn a profit on their telemedicine
networks, but substantial usage is necessary to achieve their goals
of access to quality care. 

The Council on Competitiveness' March 1996 report points out that
those who do not have access or have limited access to quality care
may stand to benefit the most from telemedicine, but they also may be
the least able to pay for these services.  Without some payment
support mechanism, infrastructure or health care providers may not
consider telemedicine alone to be capable of delivering a sufficient
return to justify their investment.  However, if multiple
applications are available to use the infrastructure, such as those
related to education or entertainment, the infrastructure costs can
be shared, and the overall return on investment can be increased. 


--------------------
\8 D.S.  Puskin.  "Opportunities and Challenges to Telemedicine in
Rural America." Journal of Medical Systems, Vol.  19, No.  3, (1995),
p.  59. 

\9 Telemedicine:  A Guide to Assessing Telecommunications in Health
Care, Institute of Medicine, National Academy of Sciences, 1996. 


   TECHNICAL BARRIERS
---------------------------------------------------------- Chapter 5:4

The lack of clinical and technical standards for transmitting data is
a major inhibitor to networking information systems.  Many agencies
and organizations will need to work together to resolve this problem. 
Radiology is the only medical specialty to develop technical
standards, which are still being revised.  Also, federal and other
users experienced another barrier--difficulties with telemedicine
equipment compatibility.  Many challenges will be encountered in
overcoming this obstacle. 


      SLOW DEVELOPMENT OF
      STANDARDS
-------------------------------------------------------- Chapter 5:4.1

Another issue complicating telemedicine is the general lack of
standards.  These standards relate to data definitions, coding or
content, and transmission of diagnostic images (e.g., speed,
resolution, and image size).  The general lack of documented record
formatting standards has been a major inhibitor to networking
information systems within and across managed care organizations and
for other players in the health care system.  Today, much of the data
content exchanged, such as the patient's relationship to the member,
is left to the interpretation of individual managed care
organizations; providers must make assumptions when coding claim data
elements and frequently use coding standards employed by the
provider's system.  According to our 1993 and 1994 reports, these
distinctions are very important to the payor and provider, since they
can affect which insurance company will be liable for a claim.\10
Also, the Council on Competitiveness' March 1996 report states that
data requirements should be clearly articulated by health care
entities, including (1) definitions of the data they need, (2) the
format in which they expect to receive such data, (3) the way in
which data should be submitted (e.g., electronically), and (4) the
frequency with which data should be submitted. 

The standard that allows formatting and exchanging of images and
associated information is known as the Digital Imaging and
Communications in Medicine.  This standard was developed by the
American College of Radiology, the first to publish standards for any
application for telemedicine, and the National Electrical
Manufacturers Association, which represents companies that
manufacture medical equipment.  Numerous government agencies and
other national organizations are involved in the health care
information standards process.\11 A number of other medical specialty
organizations are working on standards for clinical practice for
their profession, such as the American Academy of Dermatology and
American College of Cardiology. 


--------------------
\10 Health Care:  Benefits and Barriers to Automated Medical Records
(GAO/T-AIMD-94-117, May 6, 1994) and Automated Medical Records: 
Leadership Needed to Expedite Standards Development (GAO/IMTEC-93-17,
Apr.  30, 1993). 

\11 The Council on Competitiveness' March 1996 report lists 31
agencies or organizations involved in the process of setting
standards. 


      TECHNOLOGY AND EQUIPMENT
      INCOMPATIBILITY
-------------------------------------------------------- Chapter 5:4.2

Technology limitations, as well as equipment incompatibility, present
challenges for both the public and private sectors.  To successfully
implement telemedicine within the framework of the National
Information Infrastructure, interconnectivity and interoperability of
multiple systems need to be ensured.\12 For example, after purchasing
one manufacturer's telecommunication system, an Alabama VA hospital
learned that its equipment could not fully interface with another
manufacturer's equipment purchased by another VA hospital.  Worried
that this incompatibility problem could surface again, one of the
VA's Veteran's Integrated Service Network offices appointed a special
committee to handle the procurement needs for all facilities in
Alabama.  As health care providers increase use of telemedicine, they
will face increased challenges to coordinate equipment, hardware, and
software components. 

The military has also experienced equipment incompatibility problems. 
In 1994 and 1995, the battle lab at Fort Gordon, Georgia, sponsored a
Joint Warfighter Interoperability Demonstration in which industry,
academia, and others were given an opportunity to demonstrate medical
communication products with war-fighter applicability.  Several
officials associated with the demonstration told us that, during the
exercises, some demonstrations were less than successful due to
equipment incompatibility.  In one demonstration, the Army found that
its telemedicine equipment was not compatible with other Army
command, control, and communication systems.  In another exercise, a
joint service demonstration failed because one service's medical
communications equipment could not "talk" to the others.  From the
perspective of the Army Signal Corps community, these sorts of
impediments could pose serious problems on the battlefield.  The
Director of Combat Developments at Fort Gordon stated that, during an
armed conflict, the Signal Corps assumes command and control over all
communication systems, including medical communications.  The Signal
Corps worries that telemedicine equipment brought to the front will
not be able to successfully integrate with the established
battlefield communication infrastructures and therefore not be
functional during a conflict. 

Also, the emphasis placed on high-technology systems without
sufficient consideration of the specific clinical and health care
requirements and infrastructure capabilities in each setting has
created a poor fit between telemedicine system design and end-user
needs.  Given the constraints on financial resources in most
communities in need of telemedicine services, every effort should be
made to design scaleable systems that can serve the immediate and
essential clinical and health care needs at minimal cost.  Upgrading
can follow as further needs are identified and the financial
capabilities of communities increase.  As the technology expands and
the cost of equipment becomes more competitive, telemedicine systems
will be able to increase their technical capabilities.\13


--------------------
\12 Interoperability refers to the ability of different components
within a single as well as different telemedicine systems to interact
with each other without having to overcome considerable technological
barriers. 

\13 Rashid Bashshur, Dena Puskin, and John Silva.  "Telemedicine and
the National Information Infrastructure." Telemedicine Journal, Vol. 
1, No.  4 (1995), p.  349. 


      DOD'S UNIQUE TELEMEDICINE
      CHALLENGES
-------------------------------------------------------- Chapter 5:4.3

In discussing telemedicine and deployed scenarios with service
officials, we learned of circumstances that present unique challenges
for the military.  Traditionally, communications within the military
have been used to enable command and control.  Telemedicine requires
communications that are provided in a functional manner and cross
lines of command.  In addition to new linkages, more sophisticated
telemedicine technologies require the transmission of image data,
which places considerable demands on bandwidth communications. 

DOD does not have a dedicated medical communications network. 
Therefore, telemedicine communications transmissions have to compete
with other critical transmissions.  In time of war, these requests
could be for enemy coordinates or attack and defend commands.  An
Army official stated that if a medical facility used a secure
military satellite to transmit medical information to and from the
battlefield during an armed conflict, that facility would lose its
neutral zone classification.  Under the Geneva Rules of Conduct for
Warfare, the enemy can engage any facility transmitting communication
data over secured lines.  This rule makes medical facilities in
theater, normally protected from attack, open to enemy assault. 

Today, the combat medic does not have adequate means for video
communication, and military medical treatment facilities have limited
bandwidth available for telemedicine communications, both within the
theater of operations and with connections to the sustaining base. 
Further, the Navy has an extremely challenging problem, since all
data used must be transmitted and received using data links that are
already used to capacity on most ships.  Navy ships are deployed
every day, regardless of national security posture. 

Our study revealed that military personnel are concerned about
technical limitations associated with size and weight in relation to
deploying telemedicine to the battlefield.  For example, the Army's
prototype battlefield telemedicine unit in Bosnia, the Deployable
Telepresence Unit, weighs about 3 tons and takes up about 400 square
feet of space.  Until the unit's size and weight constraints can be
overcome, advancing telemedicine to the front, where the majority of
casualties occur, is not feasible. 

The Army is currently using data communications provided by the
Defense Information Systems Agency for both Primetime III deployment
to Hungary and Bosnia as well as peacetime regional telemedicine in
Region 6 (Fort Hood, Brooke Army Medical Center, and Wilford Hall Air
Force Medical Center).  This agency is leasing commercial circuits. 
Future telemedicine requirements supported by this agency will be
provided to the services as part of the agency's Global Combat
Service Support System, which is the unclassified part of the Global
Command and Control System.  According to Army Medical Command
officials, the Warfighter Information Network, which embraces
developing technologies, such as asynchronous transfer mode, fiber
optic connectivity, and personal communications system cell phones,
is expected to satisfy telemedicine bandwidth requirements on the
battlefield and provide the needed link to the combat medic serving
the combat arms. 


   CULTURAL BARRIERS
---------------------------------------------------------- Chapter 5:5

Cultural barriers must be overcome to sustain telemedicine networks
with little usage after government subsidies lapse.  These barriers
fall into two categories:  physician acceptance (which includes their
discomfort with using high-technology equipment and their skepticism
about diagnosing and treating patients at a distance) and patient
satisfaction with using telemedicine. 


      PHYSICIAN ACCEPTANCE OF
      TELEMEDICINE
-------------------------------------------------------- Chapter 5:5.1

One way to increase utilization of telemedicine networks is to foster
higher physician acceptance.  Some telemedicine projects that
experienced high usage have factors that may help other users.  For
example, officials from the Texas Department of Corrections believe
they have alleviated physician acceptance concerns through the
following actions:  (1) caregivers from referring facilities visit
the consulting physicians to discuss how consultations should be
conducted; (2) technicians at both ends of the consultation operate
the telecommunications equipment, thus freeing caregivers to perform
clinical procedures; and (3) consultants seek clinicians' advice on
how to provide better care to patients.  The findings of the Texas
study are supported by the 1995 annual report to Congress by the
Physicians' Payment Review Commission, which concluded that physician
acceptance issues may become less important as physicians gain
experience and familiarity with telemedicine services. 

However, physician acceptance continues to be an issue, according to
expert opinion and our data.  According to an American Medical News
article, among the many obstacles facing telemedicine, proponents say
"people issues" worry them the most.\14

Literature reveals that the reluctance of physicians to use
telemedicine services may be influenced by their attitudes about
quality, control of patient care and referral relationships,
convenience, and fear that urban medical centers would steal rural
patients.  For example, some uninterested doctors reported scheduling
difficulties, inability to actually examine patients, and
unfamiliarity with the technology as reasons that have deterred them
from participating in telemedicine activities. 

During our Georgia case study, various telemedicine officials often
spoke about resistance to change.  In one instance, medical personnel
at a military clinic stated they were reluctant to use the
teleradiology system primarily because they preferred having a
radiologist on hand that they knew, trusted, and could rely on.  In
addition, the radiologists at the consulting facility were
occasionally slow to respond to requests for consultations.  Some
physician resistance is due in part to the relative complexity of the
systems currently in use.  The equipment is not user-friendly;
therefore, additional training is required to learn how to operate
the equipment.  Some VA telemedicine projects have also experienced
low utilization because of physician reluctance. 

A 1995 journal article by HHS and the Telemedicine Center, Medical
College of Georgia, states that the designs of current systems are
driven more by technology than by the needs of physicians.\15 To be
successful, the article noted that telemedicine technologies may need
to adapt to the needs of physicians and patients, not vice versa. 
Training was cited as a key component of any successful telemedicine
system to help physicians with limited experience and comfort with
computers.  A June 1994 report of the Council on Medical Service,
part of the American Medical Association, cited a need for physician
education as it relates to instruction covering the spectrum from
basic computer literacy to familiarity with expert diagnostic systems
and knowledge databases.  The association's policy recommends that
designers of clinical information systems involve physicians in all
phases of system design and select technologies that are easily
mastered, flexible, and acceptable to physician users. 


--------------------
\14 "Telemedicine Coming of Age:  Friend or Foe?  Rural Doctors
Unsure." American Medical News, April 1995. 

\15 Dena Puskin and Jay Sanders.  "Telemedicine Infrastructure
Development." Journal of Medical Systems, Vol.  19, No.  2 (1995), p. 
127. 


      PATIENT ACCEPTANCE OF
      TELEMEDICINE
-------------------------------------------------------- Chapter 5:5.2

Patient acceptance with using telemedicine for consultations may be
less of a barrier than physician acceptance, particularly in rural
settings.  A few limited patient satisfaction surveys found that the
convenience of not needing to drive hundreds of miles to an
appointment with a specialist outweighs any uneasiness of not seeing
that specialist face to face.  According to one researcher, patients
in South Dakota and Florida have uniformly shown acceptance to
telemedicine.  An evaluation of the Texas criminal justice
telemedicine project found that about 70 percent of the patients
preferred telemedicine consultations to transportation to the
tertiary care hospital and another 14 percent were neutral. 

A project sponsored by the University of Kansas found that patients
were happy not to have to drive 300 or 400 miles just to see their
physician.  They also appreciated receiving a videotape of their
visits.  On the negative side, the Kansas patients found being candid
on video to be difficult and were not eager to repeat their
experiences. 


   AGENCY COMMENTS
---------------------------------------------------------- Chapter 5:6

In commenting on a draft of this report, HHS said that a clearer
depiction of the role of FDA in telemedicine was needed. 
Accordingly, we clarified this information. 


CONCLUSIONS AND RECOMMENDATIONS
============================================================ Chapter 6


   CONCLUSIONS
---------------------------------------------------------- Chapter 6:1

Telemedicine has the potential to revolutionize the way health care
is delivered.  The recent increased interest in telemedicine
technology has resulted in widespread applications throughout the
United States.  Collectively, DOD, other federal agencies, state
governments, and the private sector have already invested hundreds of
millions of dollars on numerous telemedicine projects, sometimes in
collaboration with each other.  However, it is impossible to
determine the full scope of these initiatives.  They range from
long-term research efforts exploring robotic or telepresence surgery
to pilot programs at medical facilities where some clinical
application, such as teledentistry, is actually practiced.  The most
common current clinical application is teleradiology. 

DOD and other federal agencies are actively sponsoring telemedicine
projects that individually seem justifiable and fall under the
purview of the sponsoring agency's mission.  However, not enough
comprehensive, accurate information exists to determine the
collective value of these projects.  For example, it is difficult to
tell whether DOD's investment is commensurate with the potential
benefits it stands to gain.  DOD is currently the largest federal
investor with $262 million.  On a case-by-case basis, many projects
seem justifiable, but the collective value of the DOD telemedicine
program cannot be easily assessed.  In fact, DOD's telemedicine
program is actually the sum of many individual parts and not an
interrelated group of projects prioritized to accomplish specific
goals.  Some agencies, including DOD and VA, have recognized the need
for a telemedicine strategy to define their programs but have not
moved beyond the conceptual stage.  Private sector organizations are
reluctant to share their market observations and data for fear of
revealing helpful information to their competition.  Further, because
priorities differ among the public and private sectors, working
together is even more difficult without clear and common goals. 

Successful expansion and sustainment of telemedicine will require
resolution of many legal and regulatory, financial, technical, and
cultural barriers.  Some of the more critical barriers, such as
licensure, privacy, and infrastructure costs, are too broad and have
implications too far-reaching for any single sector to address.  On
the other hand, some barriers, such as physician acceptance, can be
overcome at the local level with proper planning and management. 
Because federal agencies that directly deliver health care, such as
DOD, VA, IHS, and BOP, are less affected by licensure and
reimbursement barriers, they are better placed to provide
comprehensive information to help determine the course of
telemedicine. 

The numerous telemedicine initiatives funded by the public and
private sectors could be more productive if they were linked by
common goals, such as interdependent utilization of the information
superhighway to provide cost-effective and quality health care.  Such
a goal should complement, not supplant, individual missions, such as
improving rural or remote health care delivery, by serving as a
vehicle for sharing technical progress and avoiding duplication.  The
challenge is how to find such a link without impeding progress of an
emerging technology so difficult to define. 


   RECOMMENDATIONS
---------------------------------------------------------- Chapter 6:2

By nature, telemedicine issues cut across public and private sectors
and across agencies within the federal sector.  Although there is a
need to develop national goals and objectives to guide federal
telemedicine investments, it would be difficult for an individual
department or agency to be the architect of a governmentwide
strategy.  JWGT is already performing some interagency coordination
associated with carrying out the Vice President's charge to the
Secretary of HHS to prepare a comprehensive report on telemedicine
issues.  Therefore, JWGT is in a good position to expand its work and
take the lead in proposing a coordinated federal approach for
investing in telemedicine.  Such efforts should provide a framework
to optimize the value of federal telemedicine investments with
activities sponsored by the states and private sector. 

Accordingly, we recommend that the Vice President direct JWGT, in
consultation with the heads of federal departments and agencies that
sponsor telemedicine projects, to propose a federal strategy that
would establish near- and long-term national goals and objectives to
ensure the cost-effective development and use of telemedicine.  In
addition, the proposed strategy should include approaches and actions
needed to

  -- establish a means to formally exchange information or technology
     among the federal government, state organizations, and private
     sector;

  -- foster collaborative partnerships to take advantage of other
     telemedicine investments;

  -- identify needed technologies that are not being developed by the
     public or private sector;

  -- promote interoperable system designs that would enable
     telemedicine technologies to be compatible, regardless of where
     they are developed;

  -- encourage adoption of appropriate standardized medical records
     and data systems so that information may be exchanged among
     sectors;

  -- overcome barriers so that investments can lead to better health
     care; and

  -- encourage federal agencies and departments to develop and
     implement individual strategic plans to support national goals
     and objectives. 

Further, because DOD is the major federal telemedicine investor and
manages one of the nation's largest health care systems, it is in a
good position to help forge an overall telemedicine strategy.  A
first step is to develop a departmentwide strategy.  Therefore, we
recommend that the Secretary of Defense develop and submit to the
Congress by February 14, 1998, an overarching telemedicine research
and development and operational strategy.  The strategy should

  -- clearly define the scope of telemedicine in DOD;

  -- establish DOD-wide goals and objectives and identify actions and
     appropriate milestones for achieving them;

  -- prioritize and target near- and long-term investments,
     especially for goals related to combat casualty care and
     operations other than war; and

  -- clarify roles of DOD oversight organizations. 


   AGENCY COMMENTS AND OUR
   EVALUATION
---------------------------------------------------------- Chapter 6:3

We provided a draft of this report to DOD, VA, HHS, and the Office of
the Vice President.  Both DOD and VA concurred with our
recommendations.  DOD stated that it ".  .  .  is not alone in
finding itself behind the technological bow wave of telemedicine"
(see app.  III).  DOD said that one of its first priorities will be
the development of a definition and scope of DOD telemedicine
activities.  DOD also agreed to establish departmentwide goals and
objectives and prioritize investments as part of its strategic
telemedicine plan.  According to DOD, many pieces of this plan are
already in place.  VA commented that it would be beneficial for DOD
to include VA in its development of an operational strategy for
telemedicine activities (see app.  IV). 

After subsequent discussions with HHS officials regarding agency
comments, HHS generally agreed with the concept of our recommendation
for JWGT to play a leadership role in proposing national goals and
objectives (see app.  V).  HHS was concerned that a governmentwide
strategy could be overly prescriptive.  Our recommendation was not
intended to imply that JWGT direct federal agencies investments in
telemedicine initiatives but rather that JWGT develop a roadmap for
federal agencies to use as a guide for their investments.  HHS also
stated that it might be better to require individual departments to
develop their own strategies before an overarching federal strategy
is proposed.  We believe that individual strategies should be
developed but that these strategies would not ensure an interagency
commitment to common goals and objectives or serve as a guide to
prevent duplicative investment efforts.  We further believe that some
agencies, such as DOD and VA, might be in a better position than
others to move forward with individual strategies, whereas other
agencies would benefit from an overall federal plan to help develop
their individual strategies. 

HHS commented that JWGT had accomplished much of what we were
recommending.  We believe that JWGT should be commended for its
efforts toward fulfilling the reporting requirements to the Vice
President and the Congress.  Many indirect benefits toward informal
coordination of federal telemedicine activities are occurring. 
However, drafts of JWGT reports to the Vice President and the
Congress provided to us do not reflect a proposal for the type of
governmentwide strategy we are recommending for agencies to maximize
their telemedicine investments.  Rather, these draft reports mostly
reflect information on issues to be pursued related to barriers, such
as physician licensure, that may prevent the widespread application
of telemedicine. 

Our draft report recommended that JWGT membership be expanded to
include private and state representation.  HHS expressed concerns
about implementing this portion of the recommendation due to
requirements in the Federal Advisory Committee Act.\1

According to HHS, the act would require reimbursement for expenses of
any state or private sector representative to attend the group's
bimonthly meetings and could otherwise impair JWGT's operations.  As
an alternative, HHS suggested the addition of an annual telemedicine
summit with state and private participation to JWGT's activities.  We
believe the specific vehicle chosen is not important as long as it
improves the interaction of federal, state, and private sectors along
the lines noted in our recommendations.  Accordingly, we modified our
recommendation by deleting suggestions to expand JWGT beyond federal
agency membership.  For the same reasons, the merits of HHS' proposal
for an annual summit--certainly a constructive step--would have to be
judged against the summit's ability to foster the actions sought by
our recommendation.  We believe that JWGT should have the flexibility
to make this determination. 

Within the Office of the Vice President, the Chief Domestic Policy
Advisor and the Senior Director for the National Economic Council did
not provide us with written comments.  The Senior Director for the
National Economic Council, however, raised questions regarding the
impact of the Federal Advisory Committee Act on expanding the
membership of JWGT to include state and private membership.  Further,
DOD and HHS provided specific technical clarifications that we
incorporated in the report as appropriate. 


--------------------
\1 5 USCA App.  2 Section 1 et seq. 


ORGANIZATIONS VISITED
=========================================================== Appendix I


   FEDERAL DEPARTMENTS AND
   INDEPENDENT AGENCIES
--------------------------------------------------------- Appendix I:1


      APPALACHIAN REGIONAL
      COMMISSION
------------------------------------------------------- Appendix I:1.1


      DEPARTMENT OF AGRICULTURE
------------------------------------------------------- Appendix I:1.2

 Rural Utilities Service


      DEPARTMENT OF COMMERCE
------------------------------------------------------- Appendix I:1.3

 National Telecommunications and Information Administration
 National Institute of Standards and Technology, Advanced Technology
  Program


      DEPARTMENT OF DEFENSE
------------------------------------------------------- Appendix I:1.4

 Office of the Assistant Secretary for Health Affairs
 Air Force Surgeon General
 Army Surgeon General
 Navy Surgeon General
 Army Medical Department
 Medical Advanced Technology Management Office
 Portsmouth Naval Medical Center
 Wilford Hall Air Force Medical Center
 Madigan Army Medical Center
 Tripler Regional Medical Center
 Brooke Army Medical Center
 Walter Reed Army Medical Center
 National Naval Medical Center Bethesda
 Naval Hospital Camp Lejeune
 Armed Forces Institute of Pathology
 Defense Advanced Research Projects Agency


      DEPARTMENT OF HEALTH AND
      HUMAN SERVICES
------------------------------------------------------- Appendix I:1.5

 Food and Drug Administration
 Health Care Financing Administration
 Agency for Health Care Policy and Research
 Indian Health Service


 National Institutes of Health, National Library of Medicine
 Health Resources and Services Administration, Office of Rural
  Health Policy


      DEPARTMENT OF JUSTICE
------------------------------------------------------- Appendix I:1.6

 Bureau of Prisons


      DEPARTMENT OF VETERANS
      AFFAIRS
------------------------------------------------------- Appendix I:1.7

 Veterans Health Administration


      NATIONAL AERONAUTICS AND
      SPACE ADMINISTRATION
------------------------------------------------------- Appendix I:1.8


      NATIONAL SCIENCE FOUNDATION
------------------------------------------------------- Appendix I:1.9


   STATE GOVERNMENTS
--------------------------------------------------------- Appendix I:2

Georgia
Texas


   U.S.  HEALTH CARE ORGANIZATIONS
--------------------------------------------------------- Appendix I:3

American Academy of Dermatology
American Academy of Family Physicians
American Medical Association
Federation of State Medical Boards
American College of Cardiology
American College of Emergency Physicians
American College of Pathologists
American College of Radiology
American College of Surgeons
National Council of State Boards of Nursing
American Dental Association


   OTHER PRIVATE U.S. 
   ORGANIZATIONS
--------------------------------------------------------- Appendix I:4

Council on Competitiveness
National Electrical Manufacturers Association
National Academy of Sciences, Institute of Medicine
American Telephone and Telegraph
The Koop Foundation
Center for Public Service Communications
Computer Motion, Inc.
Western Governors Association
Allina Health Systems
Mayo Clinic


   ACADEMIA
--------------------------------------------------------- Appendix I:5

George Washington University, Intergovernmental Health Policy Project
University of Washington School of Medicine
East Carolina University


   ORGANIZATIONS WITHIN GEORGIA
--------------------------------------------------------- Appendix I:6


      DEPARTMENT OF DEFENSE
------------------------------------------------------- Appendix I:6.1

Dwight David Eisenhower Army Medical Center, Fort Gordon
Center for Total Access, Southeast Telemedicine Testbed, Fort Gordon
Tingay Dental Clinic, Fort Gordon
U.S.  Army Signal Center, Fort Gordon
U.S.  Army Health Clinic, Fort McPherson
U.S.  Army Dental Clinic Command, Fort McPherson


      DEPARTMENT OF VETERANS
      AFFAIRS
------------------------------------------------------- Appendix I:6.2

Decatur Medical Center
Augusta Medical Center


      STATE AGENCIES
------------------------------------------------------- Appendix I:6.3

Department of Administrative Services
Department of Human Resources
 Office of Rural Health and Primary Care
 Child and Adolescent Health Unit, Division of Public Health
Department of Corrections


      ACADEMIA
------------------------------------------------------- Appendix I:6.4

Center for Telemedicine, Medical College of Georgia
Robert W.  Woodruff Health Sciences Center, Emory University
Biomedical Interactive Technology Center, Georgia Institute of
 Technology



      PRIVATE ORGANIZATIONS
------------------------------------------------------- Appendix I:6.5

Georgia Baptist Hospital
The Marcus Center at Emory University
Egelston Hospital for Children, The Children's Heart Center
Scottish Rite Children's Medical Center
American Telephone and Telegraph
Panasonic
Bell South Foundation
The Georgia Power Foundation
Medasys Digital Systems


TELEMEDICINE INITIATIVES WITHIN
THE DEPARTMENT OF DEFENSE AND
OTHER FEDERAL AGENCIES
========================================================== Appendix II

Federal departments and agencies have invested in a range of
telemedicine projects.  This appendix describes some of the key
projects funded during fiscal years 1994-96 by the Department of
Defense (DOD) and the following eight federal civilian agencies:  the
Departments of Veterans Affairs (VA), Health and Human Services
(HHS), Commerce, Agriculture, and Justice; National Aeronautics and
Space Administration (NASA); National Science Foundation, and
Appalachian Regional Commission. 


   DOD IS THE LARGEST SINGLE
   FEDERAL INVESTOR
-------------------------------------------------------- Appendix II:1

DOD has invested $262 million in telemedicine initiatives over the
last 3 fiscal years.  As table II.1 shows, DARPA has invested the
most in telemedicine projects in fiscal years 1994-96, followed by
the Army (after excluding amounts spent on congressionally directed
programs).  These investments cover both battlefield and peacetime
health care. 



                               Table II.1
                
                    Telemedicine Investments by DOD
                  Organizations, Fiscal Years 1994-96

                         (Dollars in millions)

Organization                             FY 94   FY 95   FY 96   Total
--------------------------------------  ------  ------  ------  ------
DARPA                                    $20.3   $43.3   $41.0  $104.6
Army                                      15.2    51.0    60.0  126.2\
                                                                     a
Navy                                       0.1     8.5    10.5    19.1
Air Force                                  1.5     3.7     6.8    12.0
======================================================================
Total                                    $37.1  $106.5  $118.3  $261.9
                                                                    \a
----------------------------------------------------------------------
Note:  Funds provided by Health Affairs are included in the services'
investments. 

\a These amounts include $58.4 million in congressionally directed
programs. 


      DARPA FOCUSES ON UNIQUE
      BATTLEFIELD APPLICATIONS
------------------------------------------------------ Appendix II:1.1

Since 1994, DARPA has invested $104.6 million in 24 telemedicine
research and development projects.  DARPA's objective is to provide
medical care as far forward on the battlefield as possible.  Although
DARPA attempts to obtain private sector cost-sharing arrangements
when feasible, it can be difficult to obtain such arrangements early
in the research and development stage, since industry has a
short-term immediate payoff perspective.  According to DARPA
officials, its 24 projects have resulted in 86 contract awards or
partnership agreements with industry and academia participants.  Some
examples of DARPA's key projects follow. 

  -- In partnership with the Applied Physics Laboratory at the
     University of Washington and Bothwell's Advanced Technology
     Laboratories, DARPA is developing a hand-held ultrasound device
     for medics to use on the battlefield.  The device, weighing from
     2 to 4 pounds, will transmit real-time radiology images over
     communication lines to a mobile Army surgical hospital unit. 

  -- DARPA's soldier physiologic monitor is a hand-held device that
     will help the combat medic locate a wounded soldier and monitor
     the soldier's vital signs (i.e., body temperature, heart rate,
     breathing rate, and blood pressure).  Prototypes of the
     physiologic monitor are currently being tested and evaluated by
     the Army ranger school. 

  -- DARPA's Life Support for Trauma and Transport, or "Smart
     Litters," will provide built-in patient monitoring and telemetry
     as well as life support enhancements.  This project is an
     intensive care cocoon, which will provide monitoring,
     environmental control, oxygen generation, data logging and
     access, and ventilator support in a sealed environment.  The
     goal is to lengthen the golden hour (the first hour after a
     soldier is wounded) of medical care by providing critical care
     stabilization.  The survivability of a wounded soldier is
     greatly enhanced when treated and stabilized within the golden
     hour. 

  -- DARPA also has a joint project with the Georgia Institute of
     Technology and the Medical College of Georgia to develop a
     tactile sensing glove.  The goal is to develop a system for
     allowing the specialist to palpate a patient at a remote site. 
     For example, the consulting physician should be able to feel a
     mass in the remote patient's abdomen. 


      ARMY HAS BATTLEFIELD AND
      PEACETIME TELEMEDICINE
      INITIATIVES
------------------------------------------------------ Appendix II:1.2

The Army has invested $126.2 million in telemedicine since fiscal
year 1994.  These investments include approximately $46.7 million
that the Medical Advanced Technology Management Office (MATMO)
oversees, $58.4 million for specific projects directed by Congress,
and $21.1 million for other peacetime health care initiatives. 

MATMO, part of the Army Medical Research and Materiel Command, has
sponsored 21 telemedicine projects, some of which focus on
battlefield health care.  For example, MediTag is a wearable dog
tag-like device that allows the electronic storage of medical
information on the battlefield. 

Other Army organizations sponsor projects to build medical networks
in various medical treatment facilities.  These projects are mostly
related to telemedicine initiatives at U.S.  Army medical centers. 
For example, Walter Reed Army Medical Center in Washington, D.C.,
initiated medical information networks at its various medical
treatment facilities to provide telemedicine conferencing capability
for dermatology and orthopedic consultations, distance learning, and
imaging support for dental activities.  Brooke Army Medical Center in
Texas established a telemedicine connection with Darnall Army
Community Hospital that allows specialists at the center to interact
with hospital patients in clinical specialties of obstetrics and
gynecology, radiology, cardiology, pediatrics, internal medicine,
psychiatry, and nursing education.  Also, collaborative efforts
between Brooke Army Medical Center and the Air Force's Wilford Hall
Medical Center in San Antonio, Texas, are supporting clinical
consultations for TRICARE Region 6 and the Bosnia deployment. 

In addition, Congress has mandated several telemedicine projects
targeted to improve management of medical information in Army
military treatment facilities in Hawaii, Washington, and North
Carolina.  These projects are funded outside DOD's budget request and
during fiscal years 1994-96 totaled $58.4 million. 

Two projects--Akamai and the Pacific Medical Network--are based at
Tripler Regional Medical Center in Honolulu, Hawaii.  The projects
are designed to provide health care throughout the Pacific Basin by
using various telemedicine technologies.  Akamai is designed to
expand access of the Medical Digital Imaging Support (MDIS) system
and other telemedicine applications.  Akamai funding for fiscal years
1994-96 was $31 million.\1 Of these funds, about $18 million was
spent on telemedicine projects (about $13 million for MDIS and the
remaining funds for clinical diagnosis and consultations,
administrative, and evaluations) at Tripler.  Of the remainder,
Georgetown University received about $9 million, DARPA received about
$1.7 million for the soldier physiologic monitor, and Health Affairs
and MATMO used almost $2 million. 

The Pacific Medical Network is a prototype effort designed to create
a computer-based patient record that can be transmitted across great
distances and multiple time zones.  Several projects, when combined,
are expected to provide the capability to move critical patient data,
such as digital x-rays and medical history (including hospital stays,
outpatient visits, laboratory results, and immunizations), between
treatment facilities as patients are transferred from one facility to
another. 

Another congressional project, known as Seahawk, is based at Madigan
Army Medical Center in Tacoma, Washington, and designed to implement
MDIS and teleradiology and other telemedicine applications within the
Puget Sound urban environment.  The network will include all Army,
Navy, Air Force, and VA medical facilities in the area. 
Congressional funding was $6.9 million for fiscal years 1995 and
1996.  In fiscal year 1996, Health Affairs provided additional
funding of $4.8 million. 

The Walter Reed Army Medical Center is completing a 3-year
congressionally appropriated project with the Carolina Medical Center
in Charlotte, North Carolina.  The two institutions received almost
$3 million to evaluate desktop telemedicine.  Walter Reed's
expenditures included about $40,000 for computers and associated
hardware to be used at Fort Bragg, North Carolina; Fort Belvoir,
Virginia; and the National Naval Medical Center, Bethesda, Maryland. 


--------------------
\1 A March 1996 audit report by Booz-Allen and Hamilton, Inc., Akamai
Financial Rebaseline Analysis Report, was issued at the request of
Tripler officials on these appropriated funds. 


      NAVY HAS FOCUSED ON
      CONNECTIVITY WITH SHIPS
------------------------------------------------------ Appendix II:1.3

For fiscal years 1994 through 1996, the Navy funded 21 pilot projects
by reprogramming efforts at a cost of $19.1 million.  The Navy's
strategy has been directed mostly at establishing connectivity on
deployed ships with naval medical facilities based in the continental
United States.  For example, telemedicine has been used during
training exercises on selected medical facilities afloat (i.e., the
U.S.S.  George Washington and the U.S.S.  Abraham Lincoln).  The Navy
expects to integrate lessons learned from these experiences into
ships that have not yet received communications connectivity. 

The Navy Bureau of Medicine and Surgery has identified about $900
million for future telemedicine initiatives that involve
communications connectivity between deployed ships and naval medical
facilities and connections between shore-based tertiary medical
facilities and outlying clinics.  Although the Navy requested funds
for these initiatives in the fiscal year 1997 Program Objective
Memorandum, DOD officials said that the climate of funding
constraints precluded further consideration of the requests. 


      AIR FORCE EFFORTS FOCUS ON
      PEACETIME CARE
------------------------------------------------------ Appendix II:1.4

Air Force officials stated that, because both peacetime and
contingency operations use the same telemedicine applications,
experience gained from day-to-day peacetime initiatives can later be
applied to contingency operations.  During fiscal years 1994-96, the
Air Force had three ongoing telemedicine demonstrations.  These
projects were funded at a cost of $10.5 million from then-year
operation and maintenance funds. 

The most significant Air Force telemedicine effort is taking place at
Wilford Hall Medical Center.  This pilot project, in which the Air
Force is acting as DOD's TRICARE lead agent, is expected to introduce
telemedicine into the daily practice and training for health care
providers in TRICARE Region 6.  This region includes one Army medical
center and three hospitals; one Air Force medical center, eight
hospitals, and five clinics; and one Navy hospital and three branch
clinics.  According to the Office of the Air Force Surgeon General,
the project strategies developed in
Region 6 will act as a model for future regions in which the lead
agent is an Air Force medical center. 

As of May 1996, the pilot project was in its early operational stage. 
The project is expected to be phased in over 1 to 2 years to help
ensure the transition from current medical practices to clinical
telemedicine applications.  The initial stage will be a demonstration
testbed for teleconsultation and teleradiology on a small scale. 
According to the telemedicine project director, this demonstration
will provide the opportunity to evaluate administrative procedures
and technological applications and make any necessary improvements
before full implementation of the project throughout the region. 


   NON-DOD FEDERAL INVESTMENTS
   INCLUDE A WIDE RANGE OF
   PROJECTS
-------------------------------------------------------- Appendix II:2

Eight other federal departments and independent agencies have
invested in telemedicine initiatives that are consistent with their
overall agency responsibilities.  From fiscal years 1994 to 1996,
these agencies invested $384 million to deliver health care, sponsor
telecommunications development, and evaluate the effectiveness of
telemedicine systems. 


      VA FOCUSES ON TELEMEDICINE
      INFRASTRUCTURE
------------------------------------------------------ Appendix II:2.1

VA's 159 medical centers use several forms of telemedicine to help
deliver health care to its beneficiaries.  VA officials estimate
their cost to acquire the equipment and telecommunications lines was
$142 million for fiscal years 1994 through 1996.  Many of these
activities were initiated at the center level, although VA conducts
some national projects.  For example, the Baltimore Medical Center
has fully digitized its x-rays and magnetic resonance images. 
Storing all such images on computer produces better images, allows
several users to view them simultaneously, and eliminates cost and
disposal problems associated with camera film. 

Two VA medical centers, Washington and San Francisco, routinely
review the status of cardiac pacemakers worn by VA patients.  By
reviewing electronic signals via telephone lines, VA staff can
determine if a pacemaker needs to be replaced.  This review reduces
the number of unnecessary operations to replace pacemakers.  The VA
medical center near Atlanta uses its telemedicine system for
continuing medical education and training residents.  The center
receives weekly epidemiology classes from the Centers for Disease
Control and Prevention. 


      HHS INVESTS IN A WIDE ARRAY
      OF TELEMEDICINE INITIATIVES
------------------------------------------------------ Appendix II:2.2

HHS spent an estimated $110 million for telemedicine in fiscal years
1994-96 on a variety of telemedicine activities that reflect the
missions of five of its agencies, as table II.2 shows.  Many of these
grants focused on rural or remote health care delivery. 



                               Table II.2
                
                    Telemedicine Investments for HHS
                Agencies From Fiscal Years 1994 to 1996

Agency within HHS   Primary mission      FY 94   FY 95   FY 96   Total
------------------  ------------------  ------  ------  ------  ------
National Library    Research             $27.7    $0.9   $40.0   $68.7
 of Medicine
Office of Rural     Clinical health        6.9     7.6    10.1    24.7
 Health Policy       care
Agency for Health   Research               0.7     5.5     1.9     8.2
 Care Policy and
 Research
Health Care         Evaluation             4.0     0.5     3.5     8.1
 Financing
 Administration
Indian Health       Clinical               0.1     0.1     0.2     0.3
 Service
======================================================================
Total                                    $39.5   $14.6   $55.8  $109.9
----------------------------------------------------------------------
Note:  Figures do not add due to rounding. 

The National Library of Medicine was the largest HHS investor ($68.7
million) for fiscal years 1994 through 1996.  Most of this agency's
investments support research into biomedical applications of
high-performance computing and communications that could evaluate the
impact of telemedicine on health care access, quality, and cost for a
wide variety of patients.  For example, one contract with a private
firm and the University of Maryland at Baltimore will investigate the
feasibility of transmitting real-time vital sign data and video
images of ambulance patients to hospital emergency room staff. 

As the second largest investor, the Office of Rural Health Policy
provided $24.7 million in grants to private organizations to
facilitate development of rural health care telemedicine networks. 
One grant to the Eastern Montana Telemedicine Network links a
tertiary care hospital in Billings to eight community health centers
in isolated rural areas to provide mental health consultations.  A
contract with Abt Associates funded a survey of rural hospitals to
determine how hospitals were using telemedicine.  The study concluded
that teleradiology was used most frequently but that usage was very
low. 

The Agency for Health Care Policy and Research ($8.2 million)
supports research and evaluation or cost-effectiveness studies into
improving the collection, storage, and dissemination of health
information, such as patient records and clinical decision support
systems.  For example, the agency contracted with the University of
Washington to develop health care information and communication
systems policy options for state governments to increase access and
effectiveness of basic health services. 

The Health Care Financing Administration awarded $8.1 million to
demonstrate and evaluate the cost-effectiveness of telemedicine
systems, especially regarding payment methodology for telemedicine
consultations.  These funds support contractors who are evaluating
the costs and benefits of telemedicine networks located in remote
areas of Georgia, Iowa,
North Carolina, and West Virginia. 

The Indian Health Service spent about $0.3 million for telemedicine
equipment and infrastructure for its clients on remote reservations
and small communities in Alaska, Arizona, New Mexico, and Oregon. 
For example, the agency's largest project placed radiographic readers
in
10 hospitals and clinics on the Navajo Reservation.  X-rays are
scanned and transmitted to other Navajo area hospitals or the
University of
New Mexico Medical Center where consulting radiologists can provide a
diagnostic report. 

Although the Food and Drug Administration (FDA) does not invest
directly in telemedicine, it conducts in-house research into emerging
technologies to evaluate their potential public health impact.  It
also conducts research into problems with existing products and
technologies that may affect public health.  FDA ensures that medical
devices are safe and effective by establishing safety standards and
approving the manufacture and distribution of medical devices.  It
does not fund efforts for device development.  Examples of medical
devices used in telemedicine that fall under FDA's authority include
radiological imaging, transmission equipment that utilizes data
compression, and software for computer-assisted medical diagnosis. 


      COMMERCE ASSISTS PRIVATE
      SECTOR DEVELOPMENT OF
      ADVANCED TECHNOLOGY
------------------------------------------------------ Appendix II:2.3

For fiscal years 1994 through 1996, the Department of Commerce spent
about $106 million on two programs that include telemedicine among
the developing technologies they support.  The National Institute of
Standards and Technology operates the Advanced Technology Program
($93 million), which supports research into improvements in health
information management.  For example, one 1995 cooperative agreement
with a private firm will develop a voice-activated computer system to
periodically monitor homebound patients and automatically notify a
physician if problems are detected. 

The National Telecommunications and Information Administration
operates a program ($12.9 million) that grants funds to acquire
personnel, training, equipment, and services to demonstrate the use
of advanced telecommunications in health.  One award in 1995 was to
Hays Medical Center in Kansas, which is using cable television
facilities to provide home health care to remote elderly patients. 
Home health care aides in a rural area use the system to make
interactive video "house calls" to homebound patients.  Each day, a
home health aide and a patient meet for an interactive
videoconference.  The aide talks with the patient, observes the
patient's condition, and has the patient transmit medical data, such
as blood pressure or glucose level, over the cable system.  By saving
the significant travel time associated with driving from one home to
another, the project allows home health aides to see more patients,
enabling more people to stay at home instead of being transferred to
nursing homes. 


      AGRICULTURE
------------------------------------------------------ Appendix II:2.4

The Rural Utilities Service within the Department of Agriculture
administers the Distant Learning and Telemedicine Grant Program. 
This program is designed to encourage, improve, and make affordable
the use of telecommunications, computer systems, and related
technology for rural communities to improve access to education or
medical services.  During fiscal years 1994 through 1996, this
program awarded $9.3 million for telemedicine-related projects. 
Entities benefiting from the program included consortiums or
partnerships of rural hospitals, health care clinics, or other rural
health care facilities; major urban facilities also participated in
networks to extend their expertise to rural areas using advanced
telecommunications.  One grant will help support a telemedicine link
between a remote hospital in New Mexico to a medical center and
university in Albuquerque to provide teleradiology, specialist
consultations, and continuing medical education. 


      JUSTICE
------------------------------------------------------ Appendix II:2.5

In 1996, a $3.2 million telemedicine project involving the Federal
Bureau of Prisons and VA was initiated.  The Lexington, Kentucky, VA
Medical Center will be linked to four federal correctional
facilities, including one with a hospital, to provide medical
consulting services to inmate patients.  A subcontractor will
evaluate the project's results to analyze the cost benefits of the
application of telemedicine to a correctional environment. 


      NASA
------------------------------------------------------ Appendix II:2.6

Since it was founded in 1959, NASA has been developing telemedicine
technology to monitor and diagnose the condition of its astronauts in
space.  It has recently used satellites to link medical conferences
between the United States and Russia.  It also provides some support
to private sector research and development.  NASA expenditures for
telemedicine totaled $6.6 million for fiscal years 1994-96. 


      NATIONAL SCIENCE FOUNDATION
------------------------------------------------------ Appendix II:2.7

The National Science Foundation awards grants to advance research in
all fields of science.  Foundation officials identified projects
related to telemedicine in two program areas:  (1) biomedical
engineering and (2) information, robotics, and intelligence systems. 
The first program area includes awards of about $1.4 million to
improve the transmission of health information, such as
teleradiology.  The second program area awarded grants totaling $5.4
million to advance robotics performance in medical and surgical
operations. 


      APPALACHIAN REGIONAL
      COMMISSION
------------------------------------------------------ Appendix II:2.8

The Appalachian Regional Commission supports economic development in
the rural areas of 12 states.  It has awarded grants that sponsor
development of telecommunication applications that benefit the public
and private sectors.  Two projects, operating in western New York and
South Carolina, have telemedicine as their major component and
received $0.3 million from the Commission.  For example, the New York
project supports a consortium of seven hospitals that provides
specialty care, emergency medical services, and continuing
educational services to member hospitals. 




(See figure in printed edition.)APPENDIX III
COMMENTS FROM THE DEPARTMENT OF
DEFENSE
========================================================== Appendix II



(See figure in printed edition.)




(See figure in printed edition.)APPENDIX IV
COMMENTS FROM THE DEPARTMENT OF
VETERANS AFFAIRS
========================================================== Appendix II




(See figure in printed edition.)APPENDIX V
COMMENTS FROM THE DEPARTMENT OF
HEALTH AND HUMAN SERVICES
========================================================== Appendix II



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)


MAJOR CONTRIBUTORS TO THIS REPORT
========================================================== Appendix VI

NATIONAL SECURITY AND
INTERNATIONAL AFFAIRS DIVISION,
WASHINGTON, D.C. 

Sharon A.  Cekala
Valeria G.  Gist
Paul L.  Francis
Brenda S.  Farrell
Raymond G.  Bickert
Karen S.  Blum

HEALTH, EDUCATION, AND HUMAN
SERVICES DIVISION, WASHINGTON,
D.C. 

Stephen P.  Backhus
George F.  Poindexter
Jacquelyn T.  Clinton
Lawrence L.  Moore

OFFICE OF THE GENERAL COUNSEL

Dayna K.  Shah
Stefanie G.  Weldon

ATLANTA FIELD OFFICE

Cherie' M.  Starck
Gerald L.  Winterlin
Pamela A.  Scott


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