**FTS-HRSA OA**

**Moderator: Amanda Phillips-Martinez**

**August 13, 2008**

**1:00 pm CT**

Coordinator: Welcome and thank you for standing by. At this time, all
participants are in a listen only mode. During the question and answer
session, you may press star 1 on your touchtone phone if you would like
to ask a question.

Today's conference is being recorded. If you have any objections, you
may disconnect at this time.

And now I would like to turn the meeting over to Mr. Ethan Joselow. Sir
you may begin.

Ethan Joselow: All right. Good afternoon or good morning to the folks
joining us from out West. I am Ethan Joselow and I am going to be the
facilitator for today's call, TeleHealth and Telemedicine Models for
Rural Health, today, August 13, 2008.

This teleconference is brought to you by the Health Resources and
Services Administrations Office of Rural Health Policy, and it is hosted
by the Georgia Health Policy Center here in beautiful downtown Atlanta.

We have got a great lineup of speakers today, but first just a couple of
housekeeping items.

All of the speakers' slides and some additional information that they
sent on to us about their programs are available at the HRSA network
assist Web site, which there is a link on the flyer that you should have
received earlier.

If you did not receive the flyer, we can arrange for that, or you can
copy down the following URL. A bit cumbersome but here it is
http://networkassist.ruralhealth.hrsa.gov/granteecalls.shtml.

Also as (Marla), the Operator mentioned, we are going to have an audio
replay of this call available about an hour after it is completed if you
wanted to review any of the presentations or forward it on to your
colleagues.

The number to call for that replay is 1-800-262-5125. And also this call
is going to be available in transcript form.

Each of our speakers today is going to have about ten minutes, and then
we are going to open the line for questions at the end. So please hold
your thoughts until then.

Quick rundown of today's speakers. First we have Lisa Dinwiddie with
Cornerstone Care Consultants in Elko, Nevada. She will be talking to us
about mental health or about TeleHealth for dementia care in rural
Nevada with a special emphasis on Alzheimer's disease.

Julie Hall-Barrow will be next. She is joining us from the Center for
Distance Health at the University of Arkansas for Medical Sciences, and
she is going to speak to us about University of Arkansas' Telemedicine
Projects.

Jess Jamieson is the Evaluator for the San Juan County Tele-Psychiatry
program in Washington State. He is the Chairman of the Board of Advances
in Technology and he is going to speak on applications of Telemedicine
Technology and Tele-Psychiatry out in the San Juan Islands of western
Washington State.

And last joining together are going to be Johanna Barraza-Cannon and
Dena Puskin, both from HRSA. Johanna is the Director of the Division of
Health Information Technology Policy for HRSA's Office of Health
Information Technology. And Dena is the Director of the Office for the
Advancement of TeleHealth in HRSA's office of Health Information
Technology.

Together they are going to speak about experiences working with rural
telemedicine Grantees and the resources that HRSA and others have to
offer you in your rural health projects.

So without anything further, let us turn it over to Lisa Dinwiddie.

Lisa Dinwiddie: Hello everybody. I am calling from Elko, Nevada. I am
290 miles from Reno and 270 miles from Salt Lake City. We are in the
very Northeast corner of Nevada, and I hope you have my PowerPoint up.
This will make more sense if you do, as I will be speaking from that
PowerPoint.

I am one of - well as Ethan said, I am talking about Alzheimer's disease
in the frontier, the use of TeleHealth for dementia care in rural
Nevada.

On my slides, I have listed all of our partners. We are in our third
year of our HRSA Grant. I am a for-profit nursing case management
business. I contract with the University of Nevada, School of Medicine
to do the coordination for the (unintelligible) health clinic here in
Elko.

We partner, as I said, with the University of Nevada, School of
Medicine. That includes Dr. Debra Fredericks, Nurse Practitioner
Psychologist, Dr. Charles Bernick, Neurologist from Las Vegas, (Patty)
Charles, our Evaluator, and Gerald Ackerman with the Area Health
Education Center here in Elko. They help with all of the TeleHealth
equipment, and with Sylvia Elexpuru, with Brightpath Adult Enrichment
Center. She is our Grant Administrator.

I have a picture of my, you - some of you may not be able to see this,
but I have a picture of my drive home. It is of the Ruby Mountains. I
wanted to just give you a little brief description of our demographic
here in Nevada.

We - Nevada has had one of the highest percentage increases in its
senior population in the nation between 1990 and 2001. The total
population grew by 70%, but the over 50 population grew by over 100%.

In rural Nevada, 13% of our residents are over the age of 65. The
projections estimate 100% increase in the number of Nevada residents
with Alzheimer's disease, but the projection for rural seniors with
Alzheimer's will be over 150% by 2016. So there is going to be a huge
need for services.

And of course, being this frontier, service delivery is particularly
challenging because of our geographical barriers and the scarcity of
rural providers.

Nevada is the seventh largest state and the eighth most rural with an
average of 22 persons per square mile. Our urban areas are of course Las
Vegas, Reno and Carson City, the capital, and they have about 60 persons
per square mile.

Seven of Nevada's 17 counties have fewer than two persons per square
mile and Nevada also has a significantly diverse senior population whose
needs we are attempting to meet.

I want to tell you a little bit about how we came about apply for our
HRSA Grant to stand our Telemedicine clinic from (doves) working in Elko
to going to more frontier communities.

In 1994 the Las Vegas Alzheimer's Clinic was opened. It was titled 3B
Fun from the Division for Aging Services.

In 1996 the Reno Clinic opened. And that is the clinic that the nurse
practitioner psychologist runs.

In 2000, I opened the pilot clinic and a doctor flew in from Reno. Well
currently we do not even have flights from Reno coming to Elko and that
did not last long.

In 2001 we began a transition to a TeleHealth program, and in '06 we
became a full TeleHealth program with the award of the HRSA Grant.

The services that we provide are diagnosis and medical management,
social service referral, competency evaluations. We do case management
and future planning and we do behavioral consultation and counseling for
individuals and families.

So currently the main clinics are in Reno, Las Vegas and in Elko. And
then there is a slide that shows all of the smaller communities with
interactive video capabilities.

Between 2001 and 2005 some interesting things began to happen. We
started with two Monday clinics with the neurologist hooking in between
Elko and Las Vegas and then as time progressed, we added between two to
five Thursday afternoon clinics with the nurse practitioner for follow
up and for behavioral assessments, and they last about 2-1/2 hours.

Initially, I would do the screening exams and inventories. The
neurologist would validate a diagnosis with his appointment. Follow up
care would be with the nurse practitioner. And then I would meet with
families for a variety of needs to do repeat screenings, counseling,
social service referrals, case management. I also have a Nevada map just
to show you just how rural our state is.

The impetus for our TeleHealth expansion came about for several reasons.
We wanted to expand the clinical services because I had patients
commuting up to 150 miles just to hook into the TeleHealth at the Elko
Clinic. And also scheduling of appointments became more difficult and we
needed the interactive video equipment at both the nurse practitioner
and the physician's office.

We also needed to introduce education and other support services. So
because we have such a lack of consistent Alzheimer's education for
caregivers and professionals, we thought we could provide that service
over the TeleHealth system.

And it was a time that I had probably ten families that needed to be in
a support group. And so we raised this question. If the T-1 lines and
the interactive video equipment are available in other more remote
sites, why can't we see patients in their own communities?

And over that period of time, our goals were to provide excellent
patient and family care services to keep dementia patients independent
and out of long-term care facilities as long as possible, to also
provide quick turnaround time for appointments because, you know, we
wanted to make it worth their while so they did not have to drive 300
miles to Salt Lake to have an appointment.

We wanted to demonstrate the TeleHealth Alzheimer's clinic to be a
viable and important member of the medical community, that we really do
give excellent care and continuity of care and of course to positively
impact caregiving in the rurals.

And one thing we have been is a presence in our long-term care facility
and in the lives of community members.

How did we get HRSA partner buy-in and support? Well to partner was a
natural progression. All the partners were currently working together in
some capacity. The only person that we really brought in was (Patty)
Charles from the School of Medicine to do our evaluation piece.

The expansion plan to other rural and frontier towns started with the
education for caregivers and professionals. I just felt like that would
be the easiest thing to implement because it was so needed.

And then secondly to implement clinics where current patients lived. And
so what we did is we hooked in - in a community of 2000, I had three
families with very difficult Alzheimer's problems.

And so we begin in Battle Mountain. I found the rural hospitals to be
very willing to work with me and so we expanded to Battle Mountain,
Eureka, Yerington and Ely and in year two we added a couple more sites
and this year we are trying to - in fact we are working with Duck Water
Reservations to provide services up in Owyhee.

The training and implementation of the clinic, I contracted with the
local hospitals to provide site tech and clinic support. I provided
onsite training with training packets that I developed with a Medicare
Telemedicine billing instructions so each billing department would know
exactly how to bill for each patient that we have seen for that
Telemedicine time.

And then I tried to attend the first hook up at the rural sites because
there is some shock to being on the television if you have never done it
before.

And then the training and implementation for the classes, I set up the
caregiver class schedule for every other month so that we could have a
regular support group on the opposite month. And then I personally
invited families in our local clinic, and then sent flyers to outlying
areas.

And then we set up the professional Alzheimer's classes on opposite
months. And the area health education center was very helpful in helping
to do that.

We made flyers and we sent them to everybody we knew, to all of our
networking folks. The classes started in Nevada at the first year, and
in year two we expanded the services to caregivers and professionals in
rural Oklahoma. That is where your HRSA Grantee contacts come in handy.

A group in Oklahoma had lost a partner and it just so happened that we
could fill that need and that is what we are doing.

We also partner with the Alzheimer's Association and we have taken our
classes on the road. In fact, in two weeks we are going to be going to
two rural communities. The doctors are both going to be there. We are
going to provide a class for professionals, for a grand round for
physicians, community classes for caregivers and then a healthy brain
class the Alzheimer's Association is going to put on.

Then in year three we are looking to expand to Casper, Wyoming and that
is because we have a patient that has moved there. And we have some
contacts in Kentucky and we would also like to work with those more
Western states if we can possibly provide a service there as well.

And then the challenges of course for us it was getting local physician
support, very territorial. But the better, the happier their patients
were, they went back to their primary care physicians and that positive
report has helped and now we have four local physicians who are
routinely referring and we are incredibly busy.

The other challenge was as the work increased, keeping it all moving,
keeping all the balls in the air. And then of course funds for travel
and for more staff. I will say that the medical school has been a
barrier.

One challenge was the interactive video equipment is for the hard of
hearing, but we do have headphones that we are attempting to use, and
then of course every frontier community has its own personality and you
cannot assume they are all going to be the same.

Our program supporters came from many places, from word of mouth,
Division for Aging Services, the Public Guardian, Adult Day Care,
long-term care, local physicians and the biggest support were satisfied
students in the classes and patients.

And of course our friends at the Georgia Health Policy Center we just
could not have done this without Karen Wakeford and (Eileen Halloran).

Of course the Area Health Education Center, the - our successes and best
practices, I think we provide - and what makes me so enthusiastic is
that we are providing excellent integrated services.

And that the fun part is that we are providing services in communities
that we were really unplanned such as in the Oklahoma, Eastern Oklahoma.
The best part I think is if you do not have an evaluation tool that
should be one of the very first things you develop. That really helps.

The other thing is we are meeting the goals with ideas for expanding
services to include psychiatric care. Currently, Elko, which is the size
of Connecticut and the fourth largest county in the nation, we have no
psychiatric services in our county.

And then we are looking at sustainability coming through the Lou Ruvo
Brain Institute in Las Vegas, and of course, it helps if you have
people, especially in the teaching part, who understand how the
interactive video system works.

And then some other tips for you. Be sold on your program. Enthusiasm
really sells. Evaluate what you are doing and fix the problem quickly.
Expect the unexpected. Keep in close contact with your partners. Keep on
task. Do what you say you are going to do and then market, market,
market to everybody.

And then the last slide is contact names and phone numbers. If we can be
of further assistance to you it would be our pleasure. Thank you.

Ethan Joselow: Thank you Lisa. Again, if anybody has any questions or
comments, we will hold them to the end.

Right now I would like to introduce Doctor Julie Hall-Barrow calling in
from the Center for Distance Health at the University of Arkansas for
Medical Sciences. Julie?

Julie Hall-Barrow: Thank you so much. Well thank you for allowing me to
speak today, and I would hope too that everyone has the PowerPoint up
because it will make it easier to follow along with my presentation.

And the Center for Distance Health is located at the University of
Arkansas for Medical Sciences located in Little Rock, Arkansas. It is
the center of the state and we are the only academic Health Science
Center in the state of Arkansas.

So it is natural that we were taking the lead in terms of providing
Telemedicine services to hospitals across our state.

Director of our Center for Distance Health is Doctor Curtis Lowery,
Board Certified Maternal-Fetal Medicine Specialist here at UA Med, one
of three. Well he is probably our biggest champion and one of the things
I would suggest if you are thinking about Telemedicine, you really need
that physician champion to make your programs successful.

So, not only did Doctor Lowery do that for our high-risk OB programs,
but he has also done that for an entire university in other
sub-specialties.

So I will move along to our presentation now. A couple of things that
hopefully you will get out of the talk today is just a brief overview of
Telemedicine and our projects and initiatives here at the Center for
Distance Health, and some of our results in 2007 and just basic
conclusion of where we are today and where we hopefully will be
tomorrow.

Global Healthcare as we know, the Internet, patients communicate
globally, greater education and information, so Telemedicine we are
finding is more acceptable with every age group that we begin to work
with.

So, the use of computers is actually helping us move forward, not only
with the patients but also our physicians tend to be more user friendly
with the equipment because most of them are now using it within our
resident programs and some of our other training programs in our Area
Health Education Centers out in the state.

The doctor/patient relationship is changing as well as the disease
management process is changing in terms of patients wanting to access
more specialty care.

Global healthcare providership is no longer limited. We can now cross
boundaries, not only in our counties but our state, as well as other
countries, and so one of the ways that we can do that now is with
Telemedicine. And I will touch briefly on some of our international
projects toward the end of the presentation.

One of the things that we know that is happening in the healthcare
market of course is that a community is rising, the (wings of stay) is
continuing to decrease, traditional inpatients are now becoming our
outpatients and technologies will - is going to increase steadily
through these processes.

You know, what are the trends, what are the barriers that we currently
have in healthcare, and what activities do we need to pursue are some of
the questions that we continually ask ourselves as a team in the Center
for Distance Health.

And then we want to see how we can succeed at those and how do we drive
those vehicles for change within our own system. Regardless of how large
or small your system is, when you make a system change, there are
several factors that need to be integrated.

And when we began Telemedicine as many of you had if you started our
program know that there are lots of barriers. And so distance changes do
need to incur in order for you to implement as a part of your strategy.

One of the things that we say within the Center, you know, is
information and technology and communication via the Internet is not to
be mistaken as a competitive advantage of a healthcare organization, but
rather a fundamental commodity inherent in the delivery of healthcare
now and in the future.

One of Doctor Lowery's famous statements is this is healthcare and if
you are not doing it, then you are already behind. So we go along that
thought process.

Information technology is investing in healthcare. It is currently 18%
of the hospital's budget and it is most the time now requirement
especially with I am sure what Dena and the HRSA group will say in terms
of EHR and things that other small offices as well as hospitals are
encountering currently.

So an overview of the Center for Distance Health is we created the
Center as we had several groups within the Med Center doing
Telemedicine. It really was not under one umbrella.

So we created the Center for Distance Health that would service the
umbrella for all practices of Telemedicine in our Academic Health
Science Center. And that just allows us to respond to the demand for
dynamic contemporary healthcare quicker so that we have one group and
oversees all of the Telemedicine programs within the university.

A little snapshot of our state. Rural and urban areas of Arkansas, as
you can see, we are a very rural state. Our urban areas exist in the
Northwest part of the state where our Wal-Mart and Tyson industries
live. And then of course in the center of our state where Little Rock is
and many of our other top companies are.

So, the rest of the state is pretty much rural and as you can see, they
also are very medically under-served areas in Arkansas with small
pockets of where they are not.

But being very rural, we have many areas that we must connect to that
currently do not have a lot of the services that they need.

In addition to the medically under starved, the health professional
shortage areas also increased over time in the agency in that map again,
the small pockets occur in the areas of the state that tends to be more
economically than those that are not. And the same goes with our mental
health professionals so that there is an Arkansas.

Our entire state is red with just a pocket in the North and the pocket
in the center of the state. So it is really our way of connecting to
those areas.

Other part about Arkansas is that it is not a very healthy state. The
next slide shows where we rank in many of the chronic disease areas, the
morbidity mortality rate. Overall Arkansas is 46 in healthcare indices.

So what are we doing in terms of Telemedicine to try to improve that? I
have been working this out by CDH projects, other clinical operations
and some other special projects that really fall without cross those
lines.

So I will spend a little time on each of these projects. I have decided
I am in charge of the (Start) project and the Pediatrics so I may tend
to talk a little more about those two projects.

But we will try to give you in this particular area a broad overview of
all the Telemedicine activities that the Center for Distance Health is
involved in.

The first and most current project is called Arkansas SAVES. The SAVES
part stands for stroke assistance through virtual emergency support. We
are very lucky to have a very strong relationship with our Arkansas
Medicaid program which is a partner within the Department of Human
Services.

And beginning July 1 we have a \$6 million contract to provide
Tele-stroke services in ERs across our state. Working very closely with
the Department of Health in Arkansas which was very bright to use many
of their terrorism dollars to connect every hospital in Arkansas which
is 87 with a T-1 line available for video teleconferencing, all those
hospitals received at a minimum of two units, and then of course their
hospitals are wired - one line.

So we are able to use these existing networks to now connect back into
our UA Med Center for Distance Health Network and begin to provide
stroke Tele-medicine.

We are currently beginning with three small rural hospitals connected to
HUB sites, one here in Little Rock and one in Fort Smith which is an
upper part of our state and it is really allowing us to do something
that we have never been able to do before.

There is limited number of vascular neurologists in Arkansas, so we are
using vascular neurologists across the state so it is not just a UA Med
project, and then using those neurologists and placing them virtually in
some of the smaller hospitals in the state.

By the end of this project year, we should have nine of what we are
calling (HUB) site and we will have hopefully three HUB sites up and
operational by June of '09.

So we are real excited about that project and hopefully currently
Arkansas ranks last in morbidity and mortality from stroke. So we are
hoping to improve that by being able to administer TPA and have the
neurologists on board the time the patient walks through that ER in any
rural town in Arkansas.

The second project for the Prison Telemedicine program. Lots of programs
that I do prison Telemedicine. We began this very small primarily
utilizing our OB/Gen Department to provide women's health in Obstetrics
and High-Risk OB consults in the prison. The de-utilize our ANGELS Call
Center and I will talk a little bit more about that, but the prison
Telemedicine program currently delivers in two prisons that primarily
house women - state of Arkansas.

Mental health and substance abuse is a Telemedicine program that we have
had in place for a while. This is specialty psychiatry areas primarily
forensic psychiatry tends to be one of our most requested (courses) and
our psychiatry department has several contracts with other groups to
provide these services.

Train and Maintain is a program that we work with the Department of
Health on. It helps a (deploy) all the Telemedicine equipment into 87
hospitals. They were not expertise at how to showing hospital personnel
to use that equipment to be sure that it is plugged in and ready to go
at all times.

So this contracts Department of Health to provide those services. So we
hope, have an entire time that consistently goes out to the hospitals,
trains, retrains, provides education on and assist the Department of
Health in providing educational conferences for those hospitals. They
are divided in a region so there would be many regional conferences.

We are working with the UAMS Physician Call Center to provide several
different areas. One is using the 24-hour, 7 day a week, (nursing)
(unintelligible) call center - so connected to our Telemedicine program.
You talk about forensic psychiatry?

The next current project is TeleHealth KIDS which is funded through the
Office for the Advancement of TeleHealth under Doctor Ann Bynum. And
this project is connecting children in their schools in Mariana,
Arkansas where there currently is no pediatrician in that county nor is
there a hospital.

So we have nurse practitioners and a pediatrician that are in those
schools daily to provide (permanent) care and there also is an asthma
component to that project - very successful.

And the next project that kind of happened due to the growth of our
Telemedicine program within the Center for Distance Health is, we have
had many core curriculum courses that were interactive video that went
out to other community colleges and also our Area Health Education
Centers in Arkansas.

And due to the growth of the Center for Distance Health, we were able to
merge our Academic Services video conferencing group into our main
Center for Distance Health group and network. So we are kind of a
one-stop shopping now for all video conferences needs across our health
center.

Two of the In-Process programs that are currently going with the Center
for Distance Health is a Training Center. Actually August 23 our
Training Center will be up and operational.

And this will allow any group in Arkansas that is wanting to use
Telemedicine or that we are deploying Telemedicine to their Center, they
can actually come in, look at all the different types of equipment,
decide on the best equipment for them, also play with the equipment,
become used to the equipment and will also serve as our host site for
other states that want to come in and learn how to do Telemedicine.

So this Training Center will allow us to talk about network
connectivity, how to build your network, type of equipment you should
use, what kind of attachments are there out there for certain
specialties, so we are excited about this because currently we really
had to take all of our visitors and take them all around our campus
instead of them having to be at one place where everyone
(unintelligible) will now have a center where they can see all the
equipment and operate the equipment at one site.

So if that is something you are interested in, we would be happy to talk
to you about that.

The other In-Process program is really going to lean off of the stroke
project - our Arkansas SAVES project, which will allow us - there is a
current bill in our legislature that will (pub) through this session
that will provide a Trauma Network for Arkansas and hopefully utilizing
the current system that we are putting in place for stroke will now also
complement the Trauma Network and be eased by the trauma hospitals in
Arkansas to consult for other hospitals.

I will go next to our Telemedicine Clinics and other initiatives that
are currently operational.

We are currently providing rehabilitation, consult to patients across
Arkansas. And as our previous speaker said, every hospital is different,
so all of our services are not provided to all of our hospitals. It is
basically what are the needs or resources that you need at this hospital
and how we can help you fulfill those.

So rehabilitation is used and we primarily have also a large spinal
group population that it is very difficult for them to travel. Some of
them have to travel three hours, so, we have implemented the
rehabilitation Telemedicine consult.

Hematology and Oncology is also another initiative that is currently
under way for two reasons. One is to see patients that (she) was also
enrolling into clinical trials to get more rural population patients
enrolled in some of our clinical trials here at the Med Center.

Neurosurgery actually uses our programs internally and it is a large
international conferences where many patients, actually not patients,
participants come to Arkansas to train under some of our neurosurgeons
that world renown.

And they all cannot be in the surgery room at the same time, so we
utilize our Telemedicine system in the surgery room, and then the
participants can sit in a comfortable classroom and talk live to the
neurosurgeon and he can speak to them as he is performing very difficult
surgeries and they can all watch in a very large screen and have direct
communication with that surgeon as he is operating.

So we think that is kind of neat that our physicians are excited about
how to use it internally as well as externally.

Cardiology, large cardiology program. One of our physicians, Doctor
Abrahim Fahdi is a Cardiologist that has been working with an EMS
program and implementing kind of a state of the art cell phone transfer
of EKG and other information and has been awarded them foundation money
from Cingular to do this. So he is real excited about that and we hope
to expand that program as well.

Future programs that we are looking at of course is Geriatrics. We work
with the Reynolds Center for Aging here at Arkansas. We are looking for
opportunities to provide care to nursing homes as well as to Geriatric
Clinics in the state.

And another is Interpreter Services. This is also another internal and
external program. We have a limited number of Spanish interpreters and
we also have a very large Marshallese population in Arkansas. So one of
the things that we would like to do is be able to provide a robust
system in which we have interpreters within our call center with
Telemedicine capabilities and could be present in any clinic room,
hopefully in our facility or several clinic rooms within different
clinical areas and provide that real time Spanish interpreting or
Marshallese interpreting for our pilot project (things).

Ethan Joselow: Julie I am sorry to interrupt, just to keep everything
moving along on time, if you could just take maybe two more minutes.

Julie Hall-Barrow: Yes, I am just going to wrap up really quick. Just
some of the ANGELS programs which more than welcome to come onto our
ANGELS Web site, but it is the premiere program that we have with the
anti-natal, neo-natal guidelines and education learning systems.

It has many different facets, one being ANGELS CAMP, which is a separate
housing area off campus that we monitor through Telemedicine for
patients who are waiting to deliver a high-risk baby, and we need to
keep them close by but they do not really need to be on campus.

A Child Advocacy Program that is beginning, actually the equipment
arrived today to help our specialists and clinical sexual abuse cases be
able to be in advocacy centers across our state to provide real time
analysis to - for some of those sites.

A Tele-Nursery Program that is expanding. We have currently 12 sites
with Telemedicine (unintelligible) in our nursery, and it will actually
cover every nursery in Arkansas.

And then other programs that we have of course are working with the
Museum of Discovery and some educational programs. And we will begin our
Tele-ER Program starting Monday of next week to provide ER consultation
services to those hospitals that have units in their ER.

PICU will be also next. We did receive SCC funding which will allow us
to increase our Broadband access to many of our sites, and you can see
our maps, how we will expand within the next three years.

And then there is some data regarding our consultations. Twelve hundred
and ninety consults last year, many maternal transport (sees) our
ability to see the patients prior to transport and getting them here to
UAMS.

We have 52 obstetrical and 12 neonatal provider teleconference
guidelines that are available on the Web site.

I know it is a lot of information and did not talk about all the
programs that we have, but you can get to our Web site by
[www.uams.edu/cdh](http://www.uams.edu/cdh) and I am listed in the
contacts and would be happy to take any emails or calls.

Ethan Joselow: Thanks a lot Julie. There is certainly a wide scope of
work and really a model in the field out there.

I am going to turn it over now to Doctor Jess Jamieson in Washington
state.

Jess Jamieson: Well good morning out here to everybody. I hope everyone
is - had their Starbucks coffee to start your day. And what I am going
to do is really have a more narrow focus about the project that we are
working here and it is really a Tele-Psychiatry project.

And so in the state of Washington, we really are sort of like two
states. On the East side it is very rural and then on the West side it
is much more of an urban center, with the exception that when you go to
the North part of the state bumping up against the Canadian border,
there is a whole county up there which is a series of about 170 islands
and it is populated primarily with four major islands.

And as a mental health system, trying to provide services, psychiatric
services to the residents of that county, given the challenges of the
geography that was really the impetus for us to begin to think about
better ways to have the citizens in that community access psychiatric
care.

Historically one of the community mental health centers in the state
would fly a psychiatrist up there on a reasonably regular basis. But
again, just the shortage of psychiatrists and psychiatry time and the
expense associated with that really made that prohibitive.

So there was a fair amount of initiative here to try and expand the
reach of psychiatric services to the residents of that - of those
communities.

So one of the things that we looked at, and again if you are looking at
the PowerPoint presentation, the barriers for services for patients to
access psychiatric services obviously are distance and isolation, the
only way that you can get on and off the island is either fly or you
take the ferry.

And so those are both time consuming and expensive propositions. The
other issue that we ran into was again the lack of providers. There are
absolutely no psychiatrists practicing in San Juan County. There are
also no specialty providers in that region as well.

What they do have is ten primary care physicians on three of the islands
and those primary care physicians then would be the first people that
advise - that is when we started this program of the absolute need for
psychiatric resources because all of those patients fall to those
primary care physicians and again, just do not have the scope of
practice to address the psychiatric needs of the population there.

Another barrier was the funding and payment. Those health plans that
reimburse for psychiatric services, you know, tend to really focus on
in-person face to face encounters, and as we begin to talk with funders
about the reach of this kind of technology and associated payment with
that, there was a real sort of lag in terms of understanding about that,
and so that was a real barrier to put that into place.

Another thing is that we ran into was a lot of political resistance.
There are reasons why people live on those islands and one of the things
that we first encountered was when we talked about using this particular
application in the community - in these communities was, you know, we do
not want to be treated as second-class citizens in the sense that, you
know, what we really want is face to face encounters and not some kind
of TV intervention with the folks in our community.

So there was a lot of that kind of resistance to overcome. And then
frankly what we bumped into, again several years ago, was just the
overall quality of the technology in terms of patient acceptance and
also the physician acceptance of this.

So we had spent several years really trying to put this kind of
initiative in place in this community, and that really led us to making
applications to HRSA for a Grant. And that Grant was submitted by three
partners basically - the Inter Island Medical Center which is the
primary care practice with the ten physicians, Compass Health which is
the community mental health provider on the mainland that had the
responsibility of providing psychiatric coverage and services to the
people in San Juan County.

And then we had a originally a health plan that participated with us and
subsequent to that we have the local county health department who has
come on board as a partner.

So we started in May of '07 and started working with our first patient
in December. And it just took that span of time to just get all parties
on board with this new proposition.

So the - basically the goals of our Grant are to create a technology
infrastructure that gives access to psychiatry by live video. We really
wanted to be - have the capacity to serve a mix of children and adults
in this demonstration project.

We also had the agenda to convince payers to pay for Tele-Psychiatry by
demonstrating its acceptability and quality to the people that were
participating in the project.

And then to determine the characteristics of the psychiatry service that
improves experience and quality of care.

So in our application in psychiatry as opposed to other medical
specialties, one of the key issues is that interaction between the
patient and the psychiatrist.

And as we looked at all the various technologies that were out there,
the key to having this intervention work really is a sense of presence.

And the sense of presence really is a function of eye contact. And there
were - we could not find the technology application that gave us that
direct, direct. You are looking in the eyes of the patient and the
patient in turn is looking directly back at you.

The camera is - and all other applications is set off at the top or
somewhere else. And so there is this artifact of not really, when you
look into the screen, you are not really looking into the eyes of the
patient or the psychiatrist.

And so one of the things that we were able to do is we found a
technology application that solved that problem. And that was a major
breakthrough for us because that really eliminated a lot of resistance
on the part of both the patient and the psychiatrist side of the ledger.

So it is a sense of presence with eye contact. We have the capacity to
have that be a three-dimensional effect and clarity and size of the
image. They are all real sized and with high definition clarity.

There is also - there is a - in one of the slides, it is a 32" high
definition monitor that we use and it is done with reflecting the view
off a couple of mirrors. So it is a one of a kind application and we
have a partner in Texas that manufactures this particular application
and it has worked very well for us.

So, the other piece and somebody had said one of the things that is
important to do is build in an evaluation component first on. And that
was one of the things that we really spent a lot of time on ramping up
to - before we really initiated seeing our first patient.

To make certain that we really understood clearly what it is that we
wanted to accomplish with this project and that we had the various
protocols and procedures in place to make this happen.

And so, really looking at outcomes in terms of patient satisfaction, the
primary care physician satisfaction with this project and the psychiatry
satisfaction with the project were really - those were the three key
stakeholders in trying to understand, you know, what the impact of this
particular technology was.

And so essentially what the patients have reported to us, and we have a
fairly robust evaluation component, so I will not bore you with all of
that, but essentially the feedback that we get from the patients who
participate in this project is that they report to us that they
experience no real difference in seeing the psychiatrist using this
technology application as opposed to seeing the person face to face.

So it is a very positive outcome for the patient in terms of that
application. The other thing is that a huge boon to everybody is that
the convenience of not having to leave the island.

Again, if you wanted that psychiatric care, you had to take big chunks
of your day and the expense associated with leaving the island, getting
to your psychiatry appointment and then getting back to the island. It
is a whole day event basically.

And so the patients have been very positive about it. The - our
psychiatrists who have participated in the project are also very
positive about it. They really do appreciate the eye contact and the
sense of presence, and it does not seem artificial to them at all.

And they are able to do, you know, very thorough and detailed
psychiatric evaluations of patients. So it is not like doing a med check
on a follow up with a patient that you already know. These are patients
that first get to know their psychiatrist via this technology.

So the psychiatrists are also very positive about using this application
and of course the primary care physicians are please because they now
have a psychiatric resource available to their primary care patients
that need psychiatric services that was not available until this
application was put in place.

So the challenges that we still face in this project is that the sense
of depth and the 3-D component to that is still only simulated
application and there are technological applications that are currently
in process to make that truly a 3-D kind of experience.

We still are working - we do not have enough outcome data to really
demonstrate at this juncture to the various health plans that this does
make a difference.

There is a lot in the literature on medical cost offset. If you can get
people the psychiatric care that they need, their need for general
medical care is reduced.

And that is a component in the third year that we are collecting data on
to try and take a look and to see if that is true with this particular
population.

We have also experienced - we had some - we have another project that we
are working on that is not part of this Grant to install this various
application in four counties on the Eastern side of Washington, which
again is a very rural area.

And what we have encountered is that every time we install a new
application and a new system, we have to go through all the same steps
that we had to do with this particular project.

So each new install is a brand new experience because people really want
to, you know, understand that this is really going to work for them. And
so, you do not get that sort of cumulative learning experience, at least
that has been our experience.

Another part is the network. You, of course, have to have the necessary
Bandwidth in all rural areas to make this application occur.

And a final component for us is support. And it is support both to make
certain that the technology works and the people are using the
technology that they do not have to worry about it not, you know,
functioning properly because people are busy and time is of the essence.

And so our experiences in installing something like this and using this
particular application, you need to make certain that you have the
sufficient resources on the technical side to make certain everything
runs smoothly, and when you do not do that then you have problems.

And then on the patient side, you really need - our experience in terms
of again the psychiatric component is you need somebody who is there as
what we call a care manager. And that is somebody to be with the patient
through the entire interview session with the psychiatrist and follow up
with those patients just to provide the sort of ongoing support that
they may need to gain the full measure of the encounter.

So future plans for us again is we have got ten locations in four other
rural communities in rural Washington State.

We have changed the application of the unit and we have now created a
desktop version on the provider side for the patient encounter so that -
so there is more utility for a desktop unit that still gives you the
same kind of eye contact and sense of presence, but it is making the
unit smaller, more versatile to be placed in more convenient sorts of
places and locations where the psychiatrist may be.

And there has also been a fair amount of interest and we have talked
about this project and this particular technology in terms of the
military and the VA and there is a lot of conversation with folks,
excuse me, with all the post traumatic stress disorder issues that the
military is facing to consider using this particular application for all
those returning vets.

So far, it has been a very positive experience for us, and it seems to -
and that seems to be true for the patients. We have - we currently have
37 patients who are actively involved in the program and 12 of those
patients have completed the sort of a psychiatric evaluation and
treatment component and have moved out of the project and are now stable
and doing well in the community.

So we are really pleased with the support and we obviously would not
have been able to get this project up and running because no one funds
these sort of things, that had it not been for the HRSA Grant. So we are
very appreciative of that and think that it will pay good dividends to
people of San Juan County.

So thank you.

Ethan Joselow: Thank you Jess. Now we are going to turn it over to
Johanna Barraza-Cannon and Dena Puskin at HRSA.

Johanna Barraza-Cannon: Good afternoon everyone. I was just going to
give couple of brief sentences, a brief overview about our office here
at HRSA and then turn it over to Dena Puskin.

I wanted to let you know that our office is about two years old and
TeleHealth is just one component that we do here in OHIT, the Office of
Health Information Technology.

We also work on electronic health records implementation and other
health information technology. What we primarily do is award some grants
related to electronic health records and TeleHealth and also provide
technical assistance.

The attachments that I sent to you included some PowerPoint slides that
include more background on our office and on the technical assistance
here. It also includes direct contact information for the office and
some of - some background on TeleHealth.

And then I also sent you a Technical Assistance Form and I just wanted
to clarify that the form that I sent is for technical assistance related
to HIT such as electronic health records (that are you) prescribing and
there is actually a process that Dena goes through for TeleHealth
technical assistance that she will discuss.

So I just wanted to clarify that the Office for the Advancement of
TeleHealth is here in OHIT and Dena and I work very closely with our
Associate Administrator and our Division of State and Community HIT
Assistance. But the structure of our office is with the three divisions
including OAT.

So I am going to pass it over to Dena and let her use the remaining time
to tell you more about OAT. Thank you.

Dena Puskin: Thanks Johanna. For some of you, you may be familiar with
the Office for the Advancement of TeleHealth. We have been around in one
guise or another for a very long time.

We were officially formed in 1998 but our activities actually extend
back to our roots, which is the Office of Rural Health Policies where I
was at times the Deputy Director and at other times the Acting Director,
and I tenure of about ten years.

TeleHealth - its roots really come from the needs of rural areas. You
heard in the two examples given earlier, and I know from your own
experience that the issues of work force shortage has been with us for a
very long time and our inability to necessarily get all the services
that we need close to home has been an issue that has plagued rural
America since I guess time and memorial.

In our office, we have been giving out Grants to try to overcome that
barrier. And we consider TeleHealth a very broad definition of a toolbox
of different technologies.

And from our perspective basically Telemedicine which is a subset of
TeleHealth activities is the use of information and telecommunications
technologies to provide clinical care when distance separates the
participants.

And to be quite frank, some of the Grants particularly our earmark
Grants, distance may be one floor of a hospital to another.

But TeleHealth is for a broader from our perspective and our Grants
sometimes are far broader and they relate to regional health information
sharing.

We were the first funders of (realists) in this country. Our health
information exchange organizations, we, as a part of our Grants, with
the health professions, education is often part and parcel of them, the
administrative applications research and certainly a lot of homeland
security and public health.

I have also given you a handout of a talk that I gave to the Bureau of
Primary Healthcare not too long ago. And in it I have provided some
contact information on where you can get some information about the
programs.

I think for the purposes of the fact that we only have ten minutes, and
because people basically want to know where to get the money, I am going
to talk a little bit about where to get the money, at least from our
perspective.

As Johanna said, we do run some small Grant programs and we have for a
long time. And those Grant programs will be competed in 2009 of course
subject to Congress' appropriation of funds.

And so, just to tell you a little bit about the programs, we have one
program called the TeleHealth Network Grant program. And that is
basically a three-year program to support networks, vertical networks,
to essentially demonstrate how the use of these technologies can
overcome barriers to healthcare.

Particularly, we are looking more focused now on now just simply access,
but the implications for improving quality of care.

In the past round, which is concluding this year, we gave out 16 awards.
Three of those awards were specifically looking at the cost
effectiveness of home monitoring for chronic disease populations.

And the remainder of 13 were very varied from programs that address
school health and certainly almost all programs deal with mental health
services. In fact, that is the most common of frequently applied
applications.

And there are many different ways of doing so. But the reason, I think,
is pretty obviously that the needs for mental health services in rural
areas are very, very large.

Stroke - there are huge emerging areas from audiology, you name it. I
often say if you can scope it, well you can do TeleHealth.

Those programs have been historically restricted to providing services
to rural communities, even through the Grantee could be urban or rural,
the networks must be providing services to rural communities as defined
in a consistent way with the Office of Rural Health Policies Definition.

We are not sure, depending on the level of appropriation, what it will
look in the coming years, but we know that at a minimum, there will be
at least about \$3.75 million in Grants for rural provider services, and
probably more closely to \$4 to \$4-1/2 million that will come out of
that.

A second program is the Licensure Portability Grant Program dealing with
the problems of cross-state practice. And that program generally goes to
States or consortium States that are looking at breaking down the
barriers to cross state practice that are opposed by state licensure
laws.

And this past cycle, those are again three-year Grants. And those were -
two were awarded, one to the National Council of State Boards in Nursing
and one to the Federation of State Medical boards.

As a significant number of states are now entering into even with the
physicians, mutual recognitions packs, which allow physicians to
practice from one state to another.

And the nurses have the nurse compact which has been stalled somewhat.
But we believe that in order to make the federal investment in
TeleHealth optimal, we must look not only at providing seed money, but
breaking down the barriers, which does get me back to the TeleHealth
Grant program for a second, because one consortium component ad is
evaluation and lessons learned.

So that we can essentially have data that demonstrates the value added
to these programs and helps us to create policies to sustain them and
policies that support them.

One other final point about that program going back is that in the
coming year, we are hoping to have a very small and limited number of
planning Grants. The majority of Grants will be for implementation.

The final Grant program is the TeleHealth Resource Center Grant Program.
And that is the one that I think particularly we should talk about,
because if there is an interest in technical assistance, that is what
these Grants are for.

They are to create essentially regional technical assistance centers of
excellence that actually employ the experience of folks who have walked
the talk before to provide technical assistance to those to want to step
off the curb.

And in the - essentially in the slides, I have listed the Centers and
there is also, there is essentially a link to their Web site. And there
are five regional centers and they are to provide services in their
regions, but they are to work together to create a national capability
to support folks around the country.

And some of them may be familiar to you. They have a wealth of
experience. These are very, very seasoned TeleHealth programs.

And there is one national center, the Center for TeleHealth and e-health
Law in Washington whose sole purpose is to help folks deal with the
licensure, the regulatory issues, the issues regarding reimbursement,
issues that pose challenges for TeleHealth practice.

Again, those programs are going to be competed. The resource centers,
(unintelligible) health resource centers are specifically charged with
providing technical assistance to HRSA Grantees.

And I urge you, if you are thinking about a program, to contact one
(Mary) you or anyone that would interest you. And they do work together
to essentially provide assistance to you as you are looking at various
aspects of implementing a program.

We will be developing a set of tool kits that will ultimately be
available on the Web site that are based upon the experience of these
programs. But on our Web site, which is telehealth.hrsa.gov, for those
who need to get started, there is a document under Publications, which
is a guide to getting started in Telemedicine that is a little old, but
think basically helps people to step off the curb to at least examine
some of the issues that they need to look at.

I think in one of the things we want to emphasize, and we have supported
programs in this area since 1998, we have been giving funds and we have
had lots of lessons learned.

The problem we are finding is people keep on wanting to repeat the
mistakes of people who have gone before. So if there is anything I could
urge, it is to look to those who have walked the talk before.

And to help you do that, on our Web site is a Grantee directory. That
directory can, it is on telehealth.hrsa.gov and it lists all the folks
that we are currently funding or have funded in the last year or so,
with contact information.

But there are a set of charts on there that say, essentially help you if
you want to do dermatology, you can look at services and see what
programs are offering dermatology services.

And you can call folks and basically begin to talk about what you are
planning to do. And this is particularly true in mental health. I think
it is very, very important to talk to folks who have walked the talk
before because if you have seen one mental health program, you have seen
one mental health program.

There are tremendous variations. Excuse me that is my other line. And
Johanna is going to pick up my other line. So, I think it is very, very
important that you look at that.

We also have a handout on what we consider the elements of a successful
program. And these are the kinds of questions by the way, and if you
look at them that when you apply for a Grant, reviewers start to look at
these kinds of issues when looking at your program.

So I urge you to take a look at it, particularly when you are looking at
things, look at the market assessment issue. Often people want to
provide services because they think it is a good idea and they see a
need. But sometimes that need is not quite shared by others in the area.

And understanding your market, not just a theoretical need, but the
actual markets for the services is very, very critical in order to
develop successful programs.

A final lesson learned just very quickly, is you do not create referral
patterns through TeleHealth. You build upon relationships that are
already there. And over time, you may essentially build new
relationships, but your base in any new application, new program, has to
be working with folks that you have got an established relationship and
a trust relationship with.

With that I think I am going to stop and allow any questions that may
crop up.

Ethan Joselow: Thanks Dena and thanks Johanna and thank you to all of
our presenters. The way we are going to work this now is that we are
going to open up the lines for questions and comments.

Our Operator, (Marla), will give you instructions in just a second here.

Coordinator: All right, thank you. At this time, if you do have a
question, please press star 1.

To withdraw your question, press star 2.

Once again, please press star 1 to ask a question. One moment please.

Our first question comes from (Darla Boothman).

(Darla Boothman): We are one of the six rural counties in Eastern
Washington who are doing the TeleHealth for psychiatry. And we are still
trying to figure out how people are billing for those services.

Lisa Dinwiddie: This is Lisa Dinwiddie. We - our doctor bills like he
would for a regular patient visit, and then the rural site can bill for
that Telemedicine time and there is a billing manual that you can get
from Medicare.

(Darla Boothman): So you are doing just a face to face individual with a
doctor/patient and then you are billing a medicine, or a equipment code
from the rural sites.

Lisa Dinwiddie: Yes. And I cannot speak for, you know, the non-Medicare
eligible. I am sorry.

(Darla Boothman): That is okay. We were just wondering if you were doing
that, you know, one just face to face like a regular visit if they went
into the office?

Lisa Dinwiddie: Yes.

(Darla Boothman): Okay.

Dena Puskin: This is Doctor Puskin. Actually Medicare it is a little
more complicated than that. There are certain codes under psychiatry
that can get billed and others that cannot. So you need to know which
codes are billable.

(Darla Boothman): Are they specific to TeleHealth though?

Dena Puskin: Right. Specific to TeleHealth services\...

(Darla Boothman): Okay.

Dena Puskin: \...are covered in certain things under what we might
broadly consider mental health or not. Although typically the
Tele-Psychiatry codes are, but some of the counseling codes and other
things are not. So that is one thing.

The second thing is of course the site. The rural site is specified in
statute so it has to be a physician's office, a hospital, a federally
qualified health center and off the top of my head I am obviously
missing some.

Nursing homes have just been added to the equation, as have just been
added in place, in person, in-patient dialysis.

The third thing is, and I know in psychology, and the eligible
practitioners from mental health by the way are physicians and clinical
psychologist and clinical social workers.

The settings as I said are - there are a limited set of settings. So in
a rural area, most of it is going to be in a hospital or physician's
office that would be qualified. But, believe it or not, community mental
health centers are not listed.

So it is, you know, there is some real idiosyncrasies. If you are doing
mental health services to the home, it is a whole different kettle of
fish, although most psychiatrists do not.

Finally, it was mentioned that you bill to the equipment codes. No you
do not. Under Medicare, you bill for the site. There is a specific at
the remote site they get essentially a site fee, which is a specific
fee.

The billing is occurs by the psychiatrist or the eligible clinician at
the - who is providing the service, and then the remote setting gets
what is called a facility fee. And it is not an equipment code fee. It
is called a facility fee.

Medicaid in different states and in Washington state I cannot address
that. I hope someone in Washington State can, whether Medicaid covers it
and how they cover it. And private payers are very idiosyncratic.

Lisa Dinwiddie: Rural health clinics, they can bill as well. That is an
acceptable site.

Dena Puskin: Right. They are one of the acceptable sites, yes. They are
not billing. What they are getting is a practitioner who is providing
services to them can bill and they can get a facility fee.

(Darla Boothman): Thank you.

Coordinator: Again, if you have a question, please press star 1.

Ethan Joselow: If there are not any more questions, I think we will wrap
it up\...

Coordinator: We do have (unintelligible). We do have one more.

Ethan Joselow: I am sorry go a\...

Coordinator: We have one more, we have two more questions.

Ethan Joselow: Okay.

Coordinator: And (Joe Darjuling)?

(Joe Darjuling): Yes. I was just wondering if there were - if anyone
knew if there were any ED to ED Telemedicine sites up and running
anywhere.

Dena Puskin: This is Dean Puskin again. Yes, there are actually quite a
few. If you mean Affilia - not free-standing EDs, I would not be able to
address that, but hospital-based ED units, yes.

And in fact, also Intensive Care Units staff with Telemedicine. You may
have seen on TV, \'The Robot\". And so yes, there are - ED units are
essentially a growing area for Telemedicine units.

If you are talking about the hospital-based free-standing I do not think
they qualify, but I think it relates to whether they corporately, you
know, if they have the same corporate number as the hospital, hospital
number. I think that gets tricky with the free-standing and there are I
know some.

But the hospital-based ED units, yes. There are - I can tell you an
outstanding set of them around the country. If you want to contact us
later we will get you a list.

Julie Hall-Barrow: This is Doctor Julie Barrow. I know I am going to
visit Doctor (Galley) and his program at the University of Mississippi
Medical Center. He is an outstanding ER Telemedicine program. And then
of course we are launching our Children's Hospital to other ERs across
the state Monday.

Woman: And the University of Vermont has pioneered trauma services as
have a number of others where they have actually written and there is
documentation and they have done some pretty outstanding work on
documenting that.

Dena Puskin: And then some of the brain trauma work in dealing with
stroke and others have been fairly well developed, especially in
Massachusetts where they have - and Michigan where they have actually
stroke networks that are designed to provide - (unintelligible) kind of
brain.

Ethan Joselow: I am sorry. It seems that we have lost the audio here.

Dena Puskin: Have you lost it now?

Ethan Joselow: Oh that is better.

Dena Puskin: Okay. I was going to say, those, you know, in Massachusetts
and Michigan, particularly Massachusetts, they have a statewide network,
a stroke network, that really is to deal with folks who come in with
brain injury incidents of different kinds that come into the emergency
room and they provide Telemedicine consultations almost instantaneously
regarding both diagnosis and treatment.

So that is great example of actually how a state network has developed.

Ethan Joselow: Okay, is there another question?

Coordinator: Yes. The next question is from (Jean Honey).

(Jean Honey): Hi yes. We are actually introducing the Tele-Psychiatry
network in rural Maryland (Savonsot) and I was actually really
interested in what Julie had to say about introducing a call center with
Spanish interpreters and just some more information on how that was
conducted?

Julie Hall-Barrow: Hey this is Julie. Yes\...

(Jean Honey): Hi Julia.

Julie Hall-Barrow: \...so (unintelligible) there is several different
brands of software that are out there. One called (Lovie) and also use
Polycon software. There are other applications being developed right
now. But it allows like a call center to be live video linked into other
clinical areas, but they could actually do the Spanish interpreter as if
it was a Telemedicine consult. If there is a physician or nurse in that
patient's room that are not able to speak that language, then you just
turn on the Telemedicine unit and they can interpret live in that
clinical room.

(Jean Honey): Oh wonderful. Okay, thank you.

Julie Hall-Barrow: It is just another way to leverage your Telemedicine
equipment to provide care for patients that are non-speaking, you know,
English non-speaking.

(Jean Honey): So that is actually within the equipment itself.

Julie Hall-Barrow: Yes, you just do video link like you would if it was
a Telemedicine consult except you are not consulting about the
healthcare of the patient, you are actually interpreting what the
physician is saying to the patient, and then you can actually see the
patient's reactions to see if they understand, you know, what you just
told them that the physician said.

It actually provides the next level of service other than just the phone
interpreter services.

(Jean Honey): Okay great. Thank you.

Julie Hall-Barrow: Yes, we are finding it to be a real need, not only
internally but externally across the state, especially a lot of the ERs.

(Jean Honey): Right. Thank you very much.

Coordinator: All right, there is no other questions.

Ethan Joselow: Okay, thanks (Marla). And I would like to thank all of
our speakers today for their time and interest.

I think that this call has been really informative and I hope you share
that sentiment with me.

As a reminder, all the speakers' slides and some additional information
on their programs are available or will be available at the HRSA network
assist Web site. Again the URL for that information, which you can also
find on the flyer that we sent out originally, the URL, is
http://networkassist.ruralhealth.hrsa.gov/granteecalls.shtml.

Also an audio replay of this call will be available soon after it is
completed. If you would like to review any of the presentations or
forward it on to people you know, the number to call for that replay is
1-800-262-5125.

Thanks again for joining us today. This concludes our call.

END