Title: Implementing Telemedicine in Correctional Facilities
Series: Research Report
Author: Peter L. Nacci, C. Allan Turner, Ronald J. Waldron, and Eddie
Broyles
Published: National Institute of Justice, May 2002
Subject: Corrections: inmate health care
57 pages
119,723 bytes

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U.S. Department of Justice
Office of Justice Programs
National Institute of Justice

Implementing Telemedicine in Correctional Facilities

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U.S. Department of Justice
Office of Justice Programs
810 Seventh Street N.W.
Washington, DC 20531

John Ashcroft
Attorney General

Deborah J. Daniels
Assistant Attorney General

Sarah V. Hart
Director, National Institute of Justice

Office of Justice Programs
World Wide Web Site
http://www.ojp.usdoj.gov

National Institute of Justice
World Wide Web Site
http://www.ojp.usdoj.gov/nij

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Implementing Telemedicine in Correctional Facilities

U.S. Department of Justice--U.S. Department of Defense
Joint Program Steering Group Report

Peter L. Nacci, Ph.D. 
National Institute of Justice

C. Allan Turner, D.P.A. 
National Institute of Justice

Ronald J. Waldron, Ph.D. 
System Planning Corporation

Eddie Broyles 
Space and Naval Warfare Systems Command (SPAWAR)

May 2002
NCJ 190310

------------------------------

National Institute of Justice

Sarah V. Hart
Director

This program was supported under award number 98-IJ-CX-A014 to
Tracor, Inc., by the National Institute of Justice, Office of Justice
Programs, U.S. Department of Justice. Findings and conclusions of the
research reported here are those of the authors and do not reflect the
official position or policies of the U.S. Department of Justice. 

Reference herein to any specific commercial products, processes, or
services by trade name, trademark, or manufacturer, or otherwise does not
constitute or imply its endorsement, recommendation, or favoring by the
United States Government.

The National Institute of Justice is a component of the Office of Justice
Programs, which also includes the Bureau of Justice Assistance, the
Bureau of Justice Statistics, the Office of Juvenile Justice and Delinquency
Prevention, and the Office for Victims of Crime.

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CONTENTS

Executive Summary

   Planning
   Implementing the Plan
   Evaluating Needs
   Determining Cost-Benefit

Introduction

   Purpose
   Background
   Demonstration Project
   Results
   Conclusions

Implementation Decision and Planning

   Implementation Decision Process
   Implementation Planning Process

Technology Evaluation

Cost Estimation Model

Appendixes

   A. Areas of Inquiry for the Medical Requirements Analysis
   B. Telemedicine Review and Implementation
   C. Telemedicine Cost-Benefit Model
   D. Medical Requirements Analysis Worksheet
   E. Medical Requirements Analysis--Clinic Survey Form
   F. Position Description--Telemedicine Coordinator
   G. Developing Telemedicine Procedures
   H. Glossary of Telemedicine Terms

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Executive Summary

An experiment in the late 1990s and an independent evaluation of the
experiment determined that providing long-distance health care to inmates
is feasible through a system called telemedicine. Telemedicine uses
telecommunications equipment that allows health care providers to see and
diagnose inmates in prisons located far from health care providers' offices.
The experiment showed that prisons could improve inmate health care by
providing remote access to more medical specialists while reducing
prisoner transport costs and related security management costs.

The National Institute of Justice (NIJ) and Bureau of Prisons, U.S.
Department of Justice; and the U.S. Department of Defense cooperated in
the experiment. Several Federal prisons with different missions and
security levels were connected via a telemedicine network. One of the
Federal prisons was a medical center. A Veterans' Administration hospital
in Lexington, Kentucky, was also part of the network.

An independent evaluation of the experiment showed that telemedicine
could play an important role in delivering quality health care in
correctional systems. The costs and benefits vary according to the type and
nature of institution requirements, but the costs of telemedicine equipment
are continuing to decline. NIJ published a report of the evaluation in 1999
(McDonald, Douglas C., et al., Telemedicine Can Reduce Correctional
Health Care Costs: An Evaluation of a Prison Telemedicine Network,
Washington, DC: U.S. Department of Justice, National Institute of Justice,
March 1999, NCJ 175040).

The success of the telemedicine demonstration project led to the decision
to use the information from that study to develop a manual on
implementing correctional telemedicine. The information in this manual
can be used by correctional administrators who are evaluating whether
telemedicine is an acceptable approach to providing medical care in their
facility.

Planning

The first section guides the reader through the decision process. A medical
requirements analysis must be conducted to determine the services
currently provided. The satisfaction of the inmates with the current health
care services should be evaluated. Alternatives must be evaluated. If
telemedicine is selected, an action plan must be developed.

Implementing the Plan

Implementing the plan requires stating the medical requirements in terms
of telemedicine. One must know how the telemedicine system will be used
in the facility. The performance requirements of the telemedicine system
should be determined after careful analysis of state-of-the-art technology.
Communications requirements must be determined, then evaluated based
on the needs of the facility. Plans for facility requirements and necessary
modifications must be made and implemented. Personnel must be
recruited and trained for the telemedicine operation.

Evaluating Needs

The technology of telemedicine is unique and must be carefully evaluated
and implemented. The hardware, software, and system features that are
most cost effective must be identified and implemented. A variety of
communication options are available, and these also must be evaluated for
cost and capability based on the services to be provided. Space must be
identified and, if necessary, modified to meet the needs of telemedicine.
Through a careful and thorough planning and contracting process, a
successful suite of telemedicine equipment and space can be acquired and
installed.

Determining Cost-Benefit

In the final analysis, cost is an important factor. It has been demonstrated
that telemedicine can improve services, but in view of the limited funding
often provided to correctional facilities, a full cost evaluation should be
completed. To further assist in the implementation of telemedicine in
corrections, the appendixes contain tools useful for evaluating and
planning the costs of a telemedicine program.

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Introduction

Purpose

This report provides a model for estimating the relative costs of
telemedicine--the provision of health care over a distance using
telecommunications technology--under varying conditions in a
correctional setting. With the information tools provided in this document,
the correctional administrator will be able to determine if telemedicine is a
cost-effective option. Information in this report is based on a study of the
cost-effectiveness of telemedicine in a correctional system. The
companion report, Telemedicine Can Reduce Correctional Health Care
Costs, should also be consulted for information on estimating the cost of
telemedicine. Much of the information included in this report is based on
the findings of the March 1999 study. The report is available online at
http://www.ncjrs.org/ telemedicine/toc.html.

Background

Telemedicine has been under development in the United States for nearly
40 years. In the 1970s and 1980s, the number of telemedicine programs in
the United States, Australia, and Canada increased. However, the
technologies were expensive, and the programs were often canceled when
project funding ceased. Recent technological improvements in equipment
and telecommunications have made telemedicine more affordable. As a
result, various telemedicine programs are being implemented in the United
States and around the world.

Telemedicine is most useful in situations where physical barriers hinder
contact between patients and health care providers. Thus it has great
potential for use in correctional institutions. Although many U.S. prisons
maintain quality health care programs, they usually have only a small
number of physicians on staff, and many institutions have only limited
access to outside medical specialists. When specialized medical care is
required and available, prisoners must be transported outside the secure
perimeter of the prison to external medical facilities. Telemedicine allows
authorities to improve health care by providing access to more medical
specialists, while reducing prisoner transport and related security
management costs.

Demonstration Project 

In 1994 the U.S. Department of Justice and U.S. Department of Defense
signed a Memorandum of Understanding to establish a Joint Program
Steering Group (JPSG). The JPSG manages technology development and
application programs to enhance the effectiveness of the participants in
fulfilling assigned missions. The telemedicine demonstration project, a 3-
year effort that concluded at the end of 1998, was part of the JPSG's
Biomedical Technology Program. Figure 1 presents the top-level
organization of the project.

Objectives. The demonstration project was designed to assess the effect of
a correctional telemedicine network in terms of improved prisoner access
to specialty health care, lowered security risks, and more reasonable health
care costs. Secondary objectives were to identify the practical issues
encountered when designing, implementing, and integrating a
telemedicine system into an actual prison health care environment and to
derive a cost model and develop an informational tool to use when
determining the suitability of telemedicine in other applications.

Description and design of the demonstration. The JPSG wanted the project
to objectively assess the effectiveness of telemedicine in a prison
environment and determine the effect on cost, security, and overall access
to health care. The project included installing a telemedicine network to
provide remote medical consultation and electronic medical data transfer.
The institutions selected for the demonstration--the U.S. Penitentiary
(USP) in Lewisburg and USP-Allenwood (including prisoners from the
Federal Correctional Institution (FCI) in Allenwood)--are high-security
facilities located in rural Pennsylvania that incarcerate large, aging, long-
term inmate populations requiring access to a wide variety of specialized
medical care. Both prisons employed consultants to deliver these services
in their health care programs. The third site was the Federal Medical
Center (FMC) in Lexington, Kentucky, an urban, referral medical center
for both medium- and low-security inmates. Both FMC-Lexington and the
Veterans' Administration Medical Center (VAMC) in Lexington provided
hub site telemedical consultation services for the demonstration. FMC-
Lexington was also a remote site because it obtained services from the
VAMC. The locations of the facilities used in the demonstration are
shown in figure 2.

Telemedicine demonstration system. The telemedicine equipment leased
for the project included a PC-based computer workstation with required
software, an interactive videoconferencing system with multiple cameras,
compatible medical peripheral devices (such as an electronic stethoscope
and a micro/intraoral camera), and telecommunications equipment. The
various systems were linked via a telecommunications network. A generic
telemedicine system is shown in figure 3.

Results

The demonstration showed that telemedicine could play an important role
in a quality correctional health care delivery system. The costs and
benefits of telemedicine will vary with the type and nature of institution
requirements. Based on data from the study, the cost-benefit analysis
concluded that a telemedicine consultation would cost an average of $71,
compared with $173 for a conventional (face-to-face) health care
consultation--a savings of nearly 60 percent. The costs of telemedicine
equipment are continuing to decline due to advances in technology, so the
costs of telemedicine consultations should also continue to drop.

Communications can be one of the most bothersome and expensive
aspects of telemedicine operations. Sufficient telecommunications
bandwidth is key to the success of telemedicine, and available resources
will vary significantly from site to site. In this project, bandwidth on
demand was found to be the best technical solution for an operational
system and the most economical.

Well-defined participant roles and missions, agreed to in advance, are an
integral part of a telemedicine program, and training participants is
essential. Up-front training and continuing education should address the
specific needs of all participants.

Conclusions

This project demonstrated convincingly that telemedicine can be
established within a prison environment and can be widely embraced by
officials and prisoners. Telemedicine was adopted quickly and used
frequently in several medical specialty areas. Telemedicine consultations
were effective substitutes for in-person consultations in some specialties,
particularly psychiatry. Telemedicine also improved some indicators of the
quality of care available for prisoners, including the time between referral
and actual consultation, the availability of different medical specialists,
and access to doctors with more experience in treating prisoners.

Savings from such a program are most likely to result when in-prison
consultations by outside contract doctors are replaced by telemedicine
consultations. Savings from averted trips to nearby medical facilities are
more modest.

An ideal or model telemedicine system--one with all the "bells and
whistles"--is not necessary to realize significant cost savings. A simple
video teleconferencing system with a close-up camera is adequate for
many telemedicine consultations (for dermatology, for example).
Document cameras are nice, but a fax machine will usually serve just as
well. Electronic stethoscopes were found to be expensive, not often used,
and not universally accepted by doctors. Store-and-forward (see appendix
H) is good technology, but it was not evaluated in this study since personal
consultation on interactive video was readily available.

The full report, Telemedicine Can Reduce Correctional Health Care Costs:
An Evaluation of a Prison Telemedicine Network, demonstrated that
correctional agencies can add telemedicine to their medical programs and
expect health care costs to decrease.

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Implementation Decision and Planning

The effectiveness of telemedicine as a means of providing health care to a
prison population was established in the pilot project. However, each
institution, be it a prison or another isolated patient facility, has unique
problems and requirements and must determine whether telemedicine can
be used effectively in its particular situation. This section discusses the
process of deciding whether to implement a telemedicine program in a
particular institution. To assist in completing this section, appendix A
describes what data and information need to be collected and analyzed.
Appendix B contains a list of implementation questions and
considerations. Appendix H contains a glossary of terms that will be
useful in evaluating telemedicine options.

Implementation Decision Process 

Generally, telemedicine is most effective under the following conditions:

 o The medical services requirements cannot be effectively met within the
facility because--

    - The cost for onsite medical specialists is high.

    - Medical specialists are not available when needed.

    - The small number of requests for specialists does not warrant a
contract for outside services.

 o The cost to transport patients to outside medical services is very high
because--

    - Security requirements demand additional security officers and
vehicles.

    - Staff overtime is required for most outside trips.

    - Medical services are distant from the facility.

 o Other benefits will accrue from implementing telemedicine, including--

    - Improved safety to security personnel by avoiding the outside
transport of high-risk inmates or other detainees.

    - Improved safety to community and medical staff because detainees
remain in the institution.

    - Improved quality of medical care.

    - Shorter waiting lists.

    - Improved response time to inmates' medical needs.

To address these and other related issues, a coordinating committee or a
decision support group should be assembled to help conduct the review
process. This group should include not only policymakers and
decisionmakers, but also those who are familiar with the patient
population and those medical staff who might be involved in
implementing the project. Once the committee is assembled, it can use a
simplified decision matrix (figure 4) to evaluate the need for telemedicine
capabilities.

Step 1: Conduct a medical requirements analysis. A survey should be
conducted in conjunction with other information gathering to determine
whether change is required within a facility. If change is indicated, this
information will help in designing optimal solutions and evaluating the
cost of these options. The following issues should be addressed:

 o Evaluate target population demographics:

    - Numbers.
    - Age.
    - Sex.
    - Security threat.
    - Other unusual situations.

 o Review facility health care statistics:

    - Daily caseload of facility staff.
    - Consultations required or desired.
    - Transfers to outside facilities.
    - Other factors.

 o Evaluate consultation statistics:

    - Types (if any).
    - Frequency (emergency, routine).
    - Waiting time.
    - Location, availability, and qualification of consultants (bilingual?).
    - Time required for consultation.
    - Average cost for visit (internal or external).
    - Supplemental costs (such as security, transportation, etc.).

Step 2: Evaluate level of health care satisfaction within the target
population. Besides routine client surveys and health care statistics,
indicators of satisfaction or dissatisfaction with the current state of health
care within a facility can be gauged in several ways. Health care
dissatisfaction may be indicated by--

 o Grievances filed.
 o Inmate complaints to prison administrators, politicians, and media.
 o Inmate refusals of medical treatment by prison medical staff.
 o Legal cases.
 o Surveys of inmate health satisfaction.

Decision: Is change indicated? Any evident problems should be evaluated
to determine whether more specialist help is required or if basic medical
services need to be augmented. If the information indicates that a change
in health care procedures is necessary or desirable, alternative solutions
should be evaluated. 

Step 3: Review alternate solutions. The data available from the medical
requirements analysis (step 1) will indicate the scope of support required.
If telemedicine is being considered, the availability and concentration of a
cadre of medical specialty providers legally authorized to practice within
the facility are important to consider. These providers should be identified
and a close working relationship established to help build the program.
Other resources that should be identified in order to project a budget and
collect sufficient information to complete a cost-benefit analysis include
facilities, staff, and equipment.

A preliminary cost-benefit analysis should be conducted prior to
undertaking the telemedicine program (or any other solution) to provide
necessary information to support requests for budget and program
assistance. Through interaction with the medical staff of the health care
provider at the hub organization, the facility staff can use data collected in
the medical requirements analysis to develop top-level system
specifications for vendor surveys of telemedicine hardware and
telecommunications interconnects. Cost information can be derived from
these surveys. Completing the short form for the cost-benefit analysis
(found in appendix C; online at http://www.ojp.usdoj.gov/nij/ pubs-
sum/190310.htm) may provide sufficient information for preliminary
decisionmaking.

Decision: Select telemedicine? Telemedicine is not intended to replace in-
facility medical care, but it may supplement in-facility care as needed. If
specialist help is indicated, other factors concerning the availability of that
help should be evaluated, such as the location and availability of medical
specialty support. Other important considerations are the legal, political,
and human factor implications of implementing telemedicine in an
institution.

Step 4: Develop and implement action plan and milestones. Once the
telemedicine program is approved, an action plan and milestones can be
prepared. These documents identify the many actions required to
implement a successful telemedicine program. Although the schedule is
important, several other elements should be addressed, including the types
of resources required to complete the action, detailed funding sources for
the implementation, and the identity of responsible offices and individuals.
It is important that the responsible parties recognize and agree to what is
expected of them. 

The milestones identified for the project are the significant steps along the
path to implementation. For example, preparing the site within the facility
where the telemedicine consultations are to take place may consist of
several different activities--such as carpentry, electrical work, and
environmental control--all of which have scheduled completion dates.
Although completing each activity is important, the milestone is the
completion of the entire facility to permit installation of the telemedicine
hardware. The components of a detailed action plan with milestones are
contained in the next section.

Implementation Planning Process

Once the decision has been made to proceed with telemedicine, a carefully
orchestrated implementation process is important. With thoughtful
planning and attention to detail, a facility should be able to acquire, install,
and place in service a telemedicine system without significant problems.
The planning described in this section is intended to help develop the
action plan and milestones for implementing the program. The
interrelationships of the planning tasks are illustrated in figure 5. Unless
otherwise noted, these steps are applicable to either hub or remote site
planning. Each task in the process is described below. (Some of the
detailed surveys may have been completed during the decision process
described in the preceding section.)

Define medical requirements. The medical specialties to be provided with
telemedicine must be defined before the telemedicine system can be
configured. The medical diagnostic needs should have been determined in
the medical requirements analysis (step 1 of the implementation decision
process described above). The telemedicine system should be configured
to meet all current requirements and should allow graceful expansion
(adding or modifying system components, rather than replacing them) to
accommodate anticipated needs. Appendixes D and E will be helpful in
determining medical requirements.

Define telemedicine system usage. Nonmedical aspects of telemedicine
must also be defined before the telemedicine system performance can be
established. For example, should the system be portable so it can be
operated from multiple locations within the institution? Does it have to
interface with or store and transfer medical records? Is store-and-forward
capability of video, audio, or data needed? Will the system be used for
training? These features may cost money, and additional costs must be
justified. Some features, however, may save money.

Define telemedicine system performance requirements. Defining
performance requirements is probably the most important step in
implementing a telemedicine system. If this assessment is not accurate, the
system that is ultimately acquired may fail to meet actual needs or may
have costly features and capabilities that are not used.

Follow these general principles: 

 o Acquire the latest proven technology. Do not buy obsolete goods or
become a beta test site for unproven products. 

 o Make sure training and technical support are adequate--both will be
needed. 

 o Do not acquire a system unless it meets all applicable industry
standards, especially those relating to communications compatibility.

Once the basic performance requirements have been defined, the
telemedicine system can be configured to provide optimum support.
Initially, it should be configured to meet only those requirements (medical
specialties) that are most frequently used. Once this baseline system
configuration has been established and all associated costs have been
defined, it is important to verify equipment needs versus medical needs.
The cost-benefit model (see appendix C) can be used to compute the total
costs, benefits, and payback period. The procedure should then be repeated
for the less frequently used medical specialties, and the cost-benefit
recomputed. 

Define communications requirements. Defining the communications
technology required to provide satisfactory telemedicine system
performance at the lowest available cost can be challenging. During the
useful life of the system, the communications costs will far exceed the
system acquisition costs. The communications requirements depend on the
bandwidth needed for each medical specialty and the system utilization
time (minutes per month) for each specialty. This utilization pattern can
then be evaluated for each communications protocol (switched 56, ISDN,
DSL, frame relay, TCP/IP, etc.; see the glossary in appendix H for an
explanation of these and other terms). Once this information has been
collected, the communications costs can be reviewed with
communications services providers.

A different pricing strategy is generally used for the various
communications protocols. In addition, the communications services
providers may have different pricing strategies, such as discount plans and
package deals. The communications costs generally are based on line
usage (number of lines times total minutes per line times cost per minute),
or a fixed monthly fee plus line usage, or a fixed monthly fee for a
prescribed number of data packets. Because of the different pricing
schemes, the communications utilization pattern must be accurately
defined to ensure that the least expensive communications protocol has
been selected. 

Define facility requirements and modifications. The facility modifications
that a telemedicine system requires can range from modest to extensive,
depending on conditions at the institution. The following descriptions
should help planners define the tasks and costs involved in preparing a
facility for telemedicine.

 o System location. Ideally, the telemedicine system should be installed
near the health care clinic. The system must be readily accessible both to
medical personnel (to save time, especially for accessing medical records
and supplies) and to inmates (to save time and costs for inmate
movement). Figure 6 depicts possible telemedicine equipment locations.

 o Communications requirements. Generally, placing the telemedicine
room near the telephone demarcation room reduces both equipment and
installation costs for communications services. Separating them by great
distances can be costly for some communications technologies because of
the special equipment needed. (The equipment and communications
providers can help determine whether special equipment is needed.) The
telemedicine room must be equipped with a telephone in order to set up
videoconferences and perform any necessary troubleshooting. A fax
machine should be available in the room or nearby. 

 o Space requirements. The telemedicine room must be large enough to
accommodate the telemedicine system (allowing adequate viewing
distances for cameras and displays) and the personnel who operate it. If
the telemedicine room is used for training, additional seating space will be
needed. The lighting and HVAC systems of a typical office building
should be adequate for telemedicine. In some cases, especially if the floors
are not carpeted, acoustic abatement (sound absorption) will be needed.
Unless the existing electrical power service is both clean and reliable, a
power-line conditioner should be installed to protect the telemedicine
equipment from damage caused by power irregularities. The telemedicine
room must also be equipped with the furniture, fixtures, and equipment
found in a typical doctor's examination room (examination table, sink, x-
ray view box, chairs and tables, and various medical supplies).

Prepare telemedicine acquisition documents and facility modification
documents. The documents needed depend on the institution's
administrative procedures and the implementation or acquisition method
chosen. If the major tasks are being subcontracted, a telemedicine system
performance specification and statement of work, a drawing package for
the facility modification subcontractor, and (probably) drawings and
performance specifications for the communication equipment installer will
be needed. If the telemedicine system is being implemented by in-house
staff, purchase orders must be prepared for each vendor that will be
supplying equipment, material, and services.

Select communications services provider. The communications services
provider that meets the previously defined requirements at the lowest cost
should be selected. To reduce costs, this should be a competitive process.

Acquire and install communications equipment, acquire telemedicine
system and equipment, and modify facility. After all modifications and
installations are complete, the telemedicine system is ready for integration
and performance evaluation testing. Complex systems integrating many
different components from various manufacturers should be fully
integrated at the telemedicine vendor's facility before delivery. This
integration testing should reveal most problems at the vendor's facility
(where they are easily correctable), rather than at the facility in which the
telemedicine system will be implemented (where they are difficult to
correct), and should ensure that the equipment meets all requirements.
Both the hub and remote systems should be tested using the
communications method selected for each, and all performance
requirements should be tested under the most realistic conditions
achievable. These steps may not be necessary for straightforward
installations of what is basically video teleconferencing equipment.

Integrate telemedicine system. After all equipment is installed, the system
must be fully integrated and evaluated. All performance parameters should
be verified, and all problems should be corrected before the system is
accepted. It is extremely important that all integration testing be performed
accurately and completely.

Train personnel. All personnel who will operate or maintain the
telemedicine system should be thoroughly trained. All users should be able
to perform basic operations and troubleshooting; separate personnel are
not required for these tasks. Because the medical procedures for
conducting telemedicine consultation differ from those used in
conventional medicine, training must also encompass these tasks. The
demonstration project found that a telemedicine coordinator was essential
to the success of the project. Appendix F contains a position description of
a telemedicine coordinator.

Operator training is minimal due to the simplicity of the system.
Depending on the telemedicine system chosen, the system may be
operated in one of two ways:

 o With a keyboard or mouse and an on-screen user interface that leads the
operator through the required steps. 

 o With a remote control device (similar to a television remote control)
that allows the operator to proceed through the required steps using on-
screen cues.

System maintenance training is also minimal because of the self-
diagnostic capabilities of the telemedicine system. Most maintenance
problems are displayed to the operator. In addition, most systems allow the
equipment manufacturer to perform remote diagnostics by dialing into a
modem attached to the system and performing additional testing. The
failed item can then be exchanged with a replacement item sent by the
vendor (assuming the institution has a maintenance agreement with the
vendor).

Operators who will use the system for telemedicine consultations require
the most intensive training. This training should be planned well in
advance of the needed date. Hub personnel and remote site personnel will
need different training.

Start telemedicine operations. Once all the previous steps have been
successfully completed, the telemedicine system should reliably support
all telemedicine needs. Appendix G contains guidance on how to develop
procedures for conducting a telemedicine consult. 

------------------------------

Technology Evaluation

This section discusses some important issues to consider when selecting a
suite of telemedicine equipment that meets the requirements already
described. The equipment selection process translates the telemedicine
technical performance requirements into hardware and software
requirements. The information presented here should be useful in making
informed decisions when evaluating and selecting the technological
capabilities of a telemedicine system. The intent is to provide guidance in
the process, rather than to define the latest telemedicine technology (which
is constantly evolving and would soon be obsolete).

By now, the steps described under "Implementation Decision Process"
should be completed. This information is needed to identify performance
requirements for telemedicine, communications, and facilities. It also
helps identify the equipment for which relevant technology information
should be reviewed and evaluated. 

The technology evaluation process consists of three steps:

1. Determine the required hardware, software, and system features that are
most cost effective.

2. Determine the system features needed for making upgrades, expanding
performance, or changing requirements.

3. Conduct surveys of hardware, software, and system providers to
identify the sources of telemedicine products and the equipment and
services offered by each.

The extent to which the implementing organization participates in the
technology evaluation process will depend largely on the means chosen to
acquire a telemedicine capability:

 o If a systems integrator is being used, the integrator should conduct the
technology evaluations. In fact, the integrator should maintain current
information on the status of each supplier of telemedicine equipment and
services and should be able to recommend a system that provides optimum
performance to meet requirements and stays within budget.

 o If the major telemedicine project tasks are being subcontracted, all
potential subcontractors should provide the technology evaluation status of
the products they are proposing. Information should be obtained from
several candidates so that a variety of equipment from different
manufacturers can be compared.

 o If all tasks are being performed in-house, each supplier of telemedicine
products should be contacted to acquire the technology evaluation data.
With an array of manufacturers, products, and technologies to choose
from, the system can be configured using the best combination of products
and technologies to meet the facility's needs and budget.

More and more institutions are opting for a telemedicine system that is
nothing more than a videoconferencing system mounted on top of a
monitor, with one specialty camera. Several manufacturers offer
videoconferencing systems of this type. Another option is to modify
videoconferencing systems for telemedicine applications. The
modifications usually involve expanding the interface to accommodate
additional cameras and medical devices. These added features may be
considered third-party equipment, for which the system vendor does not
provide technical or maintenance support and for which no performance
guarantees are made. Unless separate agreements have been made with the
suppliers of third-party equipment, the implementing institution will likely
be responsible for the design, performance, and support of such
equipment.

Additional guidance for each technology evaluation area is provided
below.

System functions. The telemedicine system should be designed to meet
only those medical requirements that are currently needed or that will be
needed in the future. However, providing room for upgrades to software
and hardware through module replacement can minimize future
obsolescence. The telemedicine system must be easy to operate and simple
to maintain. All users must be trained to use and maintain the system. If
the system is configured properly, user training should require no more
than one session of 2 to 4 hours.

Communications. Most innovations in telemedicine technology are
occurring in communications. This is also the part of the system that will
incur the most cost over its useful life. The communications protocol
selected now may not be the most cost-effective solution in the future.
Therefore, the cost-benefit analysis should include the option of upgrading
communications at a later date.

Computers. Although the versatility and operating speed of computers
continue to improve, these improvements should not require constant
upgrades to the telemedicine system. The computer should be upgraded
only to address additions to system performance requirements or changes
to communications protocols. These upgrades can usually be
accomplished by adding or replacing modules. Generally, telemedicine
systems that do not incorporate medical records or store-and-forward
technology will not require a computer.

CODEC. The technology used to transmit telemedicine data is called an
analog-to-digital coder/decoder (CODEC). The CODEC should meet all
current standards, especially those relating to communications
compatibility. Failure to meet all standards could result in incompatibility
with other telemedicine systems.

The requirements for a facility's interface between data terminal
equipment and data communications equipment (RS-232) should be
carefully evaluated. If possible, the data ports on the CODEC should be
used for signal and data transmissions. The signals or data are thus
transmitted as "in-band" signals and do not require additional
communications channels (as opposed to transmitting them "out of band"
using separate communications channels). This feature can significantly
lower communications costs.

Technological advances have enabled telemedicine equipment designers to
incorporate the CODEC and a small video camera into one small,
relatively inexpensive unit that sits on top of a video monitor. For many
telemedicine programs, this design is adequate to capture many
telemedical consultations for considerably less than the cost of a
conventional CODEC.

Displays. Telemedicine users consider the display (monitor) to be the most
important piece of equipment, because that device provides the visual
image viewed by the medical practitioner. The resolution of the display
must be adequate for clinical needs, but a larger viewing screen is not
necessarily better. The medical users of the system should be consulted
before making a final selection. Provisions must be made for maintenance
(calibration of colors and alignment) to prevent degradation of display
quality. A quality television with a standard high-resolution connector (S-
video) is often adequate for telemedicine.

Cameras. The types of cameras needed and their capabilities depend on the
medical specialties selected for the system. As with displays, cameras
should be selected only after consulting with the medical users of the
telemedicine systems. Early systems relied heavily on an expensive "three-
chip" camera for adequate video quality. Modern single-chip cameras are
much more economical and can provide excellent video quality.

Peripheral medical devices. No specific guidance is provided for selecting
peripheral medical devices. The specialty services to be provided to the
inmates will determine the peripheral devices needed. The medical staff
should be consulted before purchasing this equipment. 

Maintenance. Unless the implementing institution has personnel with
extensive electronic technical skills, maintenance support should be
arranged through system suppliers. The implementers are not likely to
experience enough malfunctions to maintain proficiency in system
troubleshooting and repair.

------------------------------

Cost Estimation Model

A cost estimation model has been designed to help determine the benefits
of applying telemedicine in a particular institution. This model was
specifically developed to estimate the costs and benefits of using
telemedicine in a prison environment. The results of applying a similar
model are discussed in detail in the demonstration project final report. The
model described here (and presented in appendix C; online at
http://www.ojp.usdoj.gov/nij/pubs-sum/190310.htm) differs somewhat
from the one developed for the demonstration project. Although it follows
the computational methods described in the demonstration project report,
this version is more straightforward and eliminates the mathematical
complexities associated with processing large databases.

The cost-benefit model presented in appendix C is in two forms--
simplified and detailed. The simplified model is provided for situations
where budgetary estimates are desired or where detailed cost data are not
available and must be estimated. The detailed model is presented as a
series of eight linked Microsoft[R] Excel spreadsheets. It allows entry of
detailed cost data and should be satisfactory for calculating the costs and
benefits of most telemedicine projects. The detailed model can also be
tailored to the needs of a particular institution.

The cost-benefit model facilitates comparing the cost of telemedicine
acquisition and operation with that of conventional health care. The
detailed model allows the following:

 o Estimating the cost of any facility modifications that may be needed for
telemedicine installation.

 o Estimating acquisition costs of the telemedicine system, network and
communications equipment, and telemedicine room fixtures.

 o Estimating training costs.

 o Estimating the cost to operate and maintain the telemedicine system.

 o Estimating the cost to provide medical personnel to conduct the medical
consultations.

 o Estimating the medical cost savings that accrue by replacing
conventional medical care with telemedicine.

 o Estimating the transportation cost savings that accrue by replacing
conventional medical care with telemedicine.

 o Calculating the annual cost savings that accrue from telemedicine
acquisition and operation, the period required for the savings to pay back
the telemedicine acquisition cost, and the annual savings that continue to
accrue after payback of telemedicine acquisition cost.

------------------------------

Appendix A 

Areas of Inquiry for the Medical Requirements Analysis

This appendix provides sample areas of inquiry useful in conducting a
medical requirements analysis. The analysis is useful in defining the
clinical and health care requirements of an institution to ensure a good fit
between the telemedicine system design and end-user needs.

The methodology for the analysis includes interviews with medical and
administrative staff to identify the medical consultative and diagnostic
requirements for each specialty area and to gain familiarity with the
medical operations and prisoner-patient issues. Surveys can be
administered and statistics compiled on the volume and frequency of
internal and external medical consultations (i.e., visits to the prisons by
medical consultants and trips to local medical facilities, respectively) and
numbers of prisoners on waiting lists. From these statistics, the
telemedicine opportunities, clinic requirements, and other telemedicine
capabilities (e.g., mode of interaction, type of information that would be
transferred during a consultation, resolution requirements, medical
peripheral devices) can be determined. The analysis also shows the areas
with the greatest medical needs.

The medical requirements analysis is important for two reasons. First, it
helps ensure that the technology system procured will suit the medical
needs of the organization. Second, it educates the staff on telemedicine,
helps develop a rapport between the project team and telemedicine site
staff, and fosters local site support for the program.

Prison Demographics

 o Location.

    - Environment.
    - Security level.

 o Prison population.

    - Total number.
    - Population statistics.
       -- Age.
       -- Gender.

 o Prison health clinic statistics.

    - Daily case load (average).
    - Daily case load.
       -- Percent handled by in-house medical staff.
       -- Percent handled by outside consultants.
    - Specialty areas (specify).
       -- Percent handled by in-house medical staff.
       -- Percent handled by outside consultants.
    - Case types (specify).
       -- Percent handled by in-house medical staff.
       -- Percent handled by outside consultants.
    - Consultations.
       -- Percent handled by in-house medical staff.
       -- Percent handled by outside consultants.
    - Percent transferred to medical centers for consultations.

 o Medical staff.

    - Positions.
    - Required credentials or training levels.
    - Organizational structure.

Onsite Biomedical Technology and Capabilities 

List existing features.

Medical Applications: Statistics 

 o External consultations (the inmate must leave the facility).

    - Outpatient (local).
       -- Specialty area.
       -- Type cases.
       -- Routine versus emergency--percent of total external consultations.

       -- Frequency of consultations (in clinics and on-demand).
       -- Location of consultations.
       -- Costs of consultations.
       -- Percent of total consultations appropriate for telemedicine.
       -- Time required per consultation (average).
       -- Data required.
       -- Static or dynamic images, textual.
       -- Source of data (x-ray, EKG strip, etc.).
       -- Frequency of data production and transmission.
       -- Frequency of data recalled for later use.
       -- Format of data for presentation (color, hard copy, etc.).
       -- Response time for data transmission.
       -- Equipment used during consultation.
       -- Number of prisoners on waiting list.
       -- Factors causing waiting list.
       -- Total number of outpatient consultations.
       -- Total estimated hours.
       -- Medical operational procedures for consultations.
    - Inpatient (local).
       -- Specialty area.
       -- Type cases.
       -- Routine versus emergency--percent of total external consultations.
       -- Frequency of consultations (in clinics and on-demand).
       -- Location of consultations.
       -- Costs of consultations.
       -- Percent of total consultations appropriate for telemedicine.
       -- Time required per consultation (average).
       -- Data required.
       -- Static or dynamic images, textual.
       -- Source of data (x-ray, EKG strip, etc.).
       -- Frequency of data production and transmission.
       -- Frequency of data recalled for later use.
       -- Format of data for presentation (color, hard copy, etc.).
       -- Response time for data transmission.
       -- Equipment used during consultation.
       -- Number of prisoners on waiting list.
       -- Factors causing waiting list.
       -- Total number of inpatient consultations.
       -- Total estimated hours.
       -- Medical operational procedures for consultations.

 o Internal consultations (in prison).

    - Specialty area.
    - Type cases.
    - Routine versus emergency--percent of total internal consultations.
    - Frequency of consultations (in clinics and on-demand).
    - Location of consultations.
    - Costs of consultations.
    - Percent of total consultations appropriate for telemedicine.
    - Time required per consultation (average).
    - Data required.
    - Static or dynamic images, textual.
    - Source of data (x-ray, EKG strip, etc.).
    - Frequency of data production and transmission.
    - Frequency of data recalled for later use.
    - Format of data for presentation (color, hard copy, etc.).
    - Response time for data transmission.
    - Equipment used during consultation.
    - Number of prisoners on waiting list.
    - Factors causing waiting list.
    - Total number of internal consultations.
    - Total estimated hours.
    - Medical operational procedures for consultations.

 o Relocations to outside medical centers. (Transfers: The inmate must be
removed from the facility for treatment, and he/she may be transferred for
an indefinite stay at another prison hospital with broader health care
capabilities, or he/she may be transferred to a private hospital.)

    - Frequency of transfers in each specialty area.
    - Medical costs.
    - Transportation costs.
    - Administrative and overhead costs.
    - Percent of total consultations appropriate for telemedicine.

------------------------------

Appendix B

Telemedicine Review and Implementation

This appendix provides a list of considerations to review before
implementing a telemedicine program. The list has been developed in
coordination with the implementation planning process described in the
main section of this report.

The appendix is intended to give guidance in considering those factors
involved in implementing a telemedicine program. In this sense, it is a
reminder to consider and evaluate all technical, performance, and cost
areas so the institution can acquire the telemedicine system that best meets
its needs. Thus, this list duplicates some information found in other parts
of the report.

Implementing a telemedicine system is usually an iterative process. As
you proceed through the required steps, you will need to reevaluate prior
steps to ensure that the decisions made are still the best choices. You may
determine that previous choices must be changed and the succeeding steps
repeated.

Can Telemedicine Satisfy Your Institutional Requirements? 

 o Can telemedicine save money? This is often the most difficult question
to answer in advance. The cost-benefit analysis conducted for the
telemedicine demonstration project1 clearly shows that telemedicine can
save money for facilities similar to the demonstration project. Completing
the cost-benefit model in appendix C will help answer this question for
your facility.

 o Can telemedicine provide better health care? If access to health care is
limited because of a remote location, limited availability of nearby health
services, excessive costs of local health care, security concerns, or
contractual or administrative restrictions, telemedicine can often be
especially beneficial. Telemedicine usually provides more accessible
medical care where local conditions restrict access to physicians or
medical facilities.

 o Can telemedicine reduce liability? If telemedicine is used correctly, it
may reduce medical liability by making medical services more readily
available and by fully documenting (through audio or video recording) the
medical consultations of sensitive cases.

 o How will telemedicine affect inmate management?

 o Which organizations (departments) should be involved in implementing
and using telemedicine?

 o What resources are available for implementing telemedicine (resources
within your facility that have sufficient time to devote to telemedicine
acquisition)?

    - Management.
    - Contractual.
    - Financial.
    - Technical.

 o Based on the resources available, which acquisition method should be
used?

    - Contract the tasks to a full-service organization.
    - Manage the project, but subcontract major tasks.
    - Perform the acquisition and installation tasks using in-house
resources.

 o What type of contract (or interagency agreements) will be required to
establish the remote-hub working relationships?

 o Who schedules consultations? What are the logistics of scheduling
consultations, resolving schedule conflicts, and handling emergencies?

 o How will cost invoicing and reimbursement be managed?

Define Medical Requirements 

 o Which medical specialties and subspecialties are required to meet
current health care needs?

 o Can telemedicine serve the medical diagnostic requirements for the
specialties and subspecialties needed?

 o Will the telemedicine system use rate be sufficient to justify its
acquisition (i.e., how many consultations per specialty per month would be
conducted using telemedicine)?

 o Remote-site issues: Where will the hub site be located? Can it support
our health care needs at the required utilization rate? What are the
individual (or per hour) consultation costs for each medical specialty?

 o Hub-site issues: Will we be working with one or many remote sites?
Will there be enough (or too many) requests for consultations for each
specialty?

Define Telemedicine System Usage (Both Medical and Nonmedical
Applications) 

 o In addition to medical consultations, what will the telemedicine system
be used for?

    - Inmate counseling (social, psychiatric, medical).
    - Training of inmates or staff.
    - Medical training and recertification of health services personnel.
    - Arraignment.
    - Judicial proceedings.
    - Video conferences (prison staff).
    - Attorney-inmate conferences.

 o From how many locations within the facility must the telemedicine
system be accessible?

    - One (fixed system location).
    - More than one (portable system or multiple systems).

 o Will the telemedicine system be integrated  (initially or in the future)
with our local area network or wide area network, or should it be separate?

 o Will the telemedicine system be used to generate, transfer, or maintain
medical records or administrative data?

 o Will the telemedicine system be integrated with medical or
administrative systems?

 o Will remote (not located in the telemedicine room) consoles be needed
to view the consultations or examine records?

 o Should the telemedicine system have a store-and-forward capability, or
should the consultations be interactive? If the former, which store-and-
forward capabilities are needed?

    - High-definition video still images.
    - Video clips.
    - Audio clips.
    - VCR recordings.
    - Data files (medical or administrative records).
    - Storage devices (type and capacity).

 o Should the telemedicine system incorporate radiology?

Define Telemedicine System Performance Requirements 

This task translates the medical and other system usage requirements into
performance requirements for the telemedicine system. If you are
employing a full-service contractor or are subcontracting the major
implementation tasks, the contractor should help you prepare a
performance specification for a telemedicine system that is appropriate for
your needs. If you are performing all tasks in house, you must determine
the performance requirements for the hardware and software that you
need. This is not as difficult as it may seem, because several vendors sell
videoconferencing or telemedicine systems that are already integrated and
may meet most of your needs. You may have to add third-party equipment
to complete your system.

Once you know the telemedicine system performance requirements, you
can research which available products meet your needs. Use the Internet
and trade magazines to locate vendors offering the products and services.
You can often download the necessary technical, availability, and cost data
from the Internet. Otherwise, contact the vendor directly for the necessary
information.

Now you are ready to configure the telemedicine system that best meets
your needs and budget from the array of available products and services.

Define Communications Requirements 

Based on the information developed thus far, you should know the types
of medical consultations to be performed each month, the estimated time
(minutes per month) online with each medical specialty, and the
communications bandwidth necessary for each specialty. Now you need to
determine which communications protocols are available at your location.
Consider the following (see glossary at appendix H for details):

 o Switched 56.
 o Integrated services digital network (ISDN).
 o Digital subscriber line (DSL).
 o Asynchronous transfer mode (ATM).
 o Frame relay.
 o Transmission control protocol (TCP)/Internet protocol (IP).

Your selection of communications protocols may be limited because--

 o An existing protocol must be used at your facility.
 o You must match the protocol used by a remote site.
 o The desired protocol may not be available at your location.

When selecting the communications protocol, you must consider any
unusual conditions that may exist at your facility. Since most
communications services providers will terminate the communications
lines in the telephone demarcation room, your proximity to the
demarcation room may influence your selection of protocols. Carefully
evaluate communications performance if the telemedicine system must be
operated from multiple locations or if the distance from the telemedicine
room to the demarcation room requires the electrical signals to be
converted and transmitted over a fiber-optic cable.

Define Facility Requirements and Needed Modifications 

Facility modifications can range from none to extensive. Usually, older
facilities require more extensive modifications than newer ones.

 o Location considerations.

    - Near communications facilities.
    - Near medical records.
    - Easily accessible by medical staff.
    - Conveniently located for patients (if remote site).
    - In a quiet area without background noise.
    - Security can be maintained and not compromised.

 o Configuration considerations.

    - Room shape allows proper placement of equipment and fixtures.

    - For jails and prisons, inmate examination area allows egress route for
medical personnel.

    - Space is available for auxiliary seating if equipment or room is used
for training, videoconferences, or visitors.

    - Ingress and egress do not require patients to cross over cables or
interfere with camera views and do not allow them to tamper with
equipment.

    - For jails or prisons, doors are not lockable from inside. (Doors should
be locked when the telemedicine system is not in use.)

 o Lighting.

    - Adequate lighting, evenly distributed, without glare or shadows.
    - Variable light intensity (desirable--not required).

 o Acoustics: Most rooms require some type of acoustic treatment for
good audio performance. There should be no distracting background
noises. This is critical when using electronic stethoscopes (at both hub and
remote sites). Confidential medical discussions should not be audible
outside the telemedicine room. Treating acoustic problems generally
proceeds in the following order:

    - Carpet the floor.
    - Insulate the ceiling, especially if a suspended ceiling is used.
    - Insulate the walls.
    - Install sound absorption on the walls.

 o Electrical.

    - 110-volt, 15-ampere service is adequate for most systems.

    - An uninterruptible power supply (UPS) is not normally required, but
is highly desirable. If your facility experiences frequent power outages,
voltage drops or surges, or spikes on the power line, a UPS is essential.

 o HVAC: The temperature and environmental controls of a typical office
building are satisfactory. Additional HVAC may be needed for training or
videoconference equipment.

Prepare Telemedicine Acquisition Documents 

The specific acquisition documents needed will depend on your
administrative procedures and the acquisition method chosen.

 o Administrative documents.
 o Contracts, subcontracts, purchase orders.
 o Statements of work.
 o System performance specifications.
 o Technical specifications for equipment.
 o Testing procedures, both factory acceptance and onsite acceptance.
 o Maintenance and support agreements.
 o Shipping instructions.

Prepare Facility Modification Documents 

If facility modifications are required (and especially if they are to be
subcontracted), all modifications should be described in documents that
are standard to building practices in your area for the building trades
involved. As a rule, the documentation formats established by the
American Institute of Architects should be followed.

Most facilities require approval of the facility manager before any
modifications are permitted. After the facility is modified, the building
drawings and specifications should be updated to the "as-built" conditions:

 o Building or modification permit (if required by local code or
regulations).

 o Drawings or specifications (for each building trade to be
subcontracted).

 o Inspection records.

Select Communications Services Provider 

Sometimes selection of the communications services provider is controlled
by conditions outside the telemedicine project:

 o Your organization already has a service agreement with a particular
provider.

 o Operation with the hub (or remote) site restricts your choices.

 o Other users of the communications services may affect your decision.

Unless there is some overriding reason to the contrary, the
communications services provider should be selected based on lowest
cost. However, lowest cost is sometimes difficult to determine, because
each service provider has different cost structures. If available, your
expected communications utilization pattern should form the basis for cost
comparisons.

Acquire and Install Communications and Telemedicine System
Equipment; Modify the Facility 

All these tasks should be accomplished on the basis of documents
developed earlier. You will need to maintain cost and schedule control
during this period to avoid exceeding your budget or missing deadlines. 

Integrate the Telemedicine System 

Your telemedicine system should be integrated twice: first at the system
integrator's facility (or at your facility if you are integrating the system)
and again after the system is installed. This step assumes that you are
acquiring both hub and remote systems.

The systems should be fully integrated and all performance parameters
verified while the systems are at the same location. System performance
can be verified and problems resolved more efficiently and with a smaller
technical staff if all parties can witness the performance of both the hub
and remote systems. If possible, during testing at the system integrator's
facility, use the same communications methods and protocols that will be
used for the final installation, even to the extent of transmitting the signals
outside your facility in a loopback configuration.

After the hub and remote systems have been installed onsite, the
integration tests previously performed should be repeated. (The difficulty
of resolving any remaining problems will quickly illustrate the value of the
previous integration testing.) If the integration testing is performed
thoroughly and all problems are corrected, you should not experience any
major technical problems when operating your telemedicine system.

Train Personnel

Conduct training in accordance with training plans. If possible, training
should be conducted onsite, using the actual telemedicine system
implemented for your program. All personnel using telemedicine for the
first time should be permitted an additional period of hands-on operation
to thoroughly familiarize themselves with their new tasks.

Start Telemedicine Operations 

Congratulations! You have now completed the telemedicine acquisition
process. You will probably be surprised how quickly everyone adapts to
tele-medicine and takes advantage of all the benefits it provides.

------------------------------

Appendix C

Telemedicine Cost-Benefit Model

The cost-benefit model presented in this appendix allows you to calculate
the cost of acquiring a telemedicine system, the fiscal savings you can
expect from using such a system, and other cost-benefit values. Two
models are provided: a simplified model for initial cost evaluation and
budget planning and a detailed model for calculating more precise and
comprehensive costs based on estimates received from material providers,
equipment suppliers, and subcontractors; telemedicine system operating
costs; and financial savings that accrue from using telemedicine. The
simplified cost estimation model is a single page, whereas the detailed
model is eight pages. (In electronic form, these pages are linked
spreadsheets.)

The cost models used in this report were developed using Microsoft[R] 
Excel; however, other commercial spreadsheets would be suitable for this
purpose. Electronic copies of the spreadsheets used in this report are
available online at http://www.ojp.usdoj.gov/nij/pubs-sum/190310.htm.
The embedded formulas in the electronic copies are not detailed in this
summary. The reader is strongly encouraged to download electronic copies
of the model spreadsheets and become familiar with the formulas.

In both models, highlighted cells have been protected and do not permit
data entry (without password), to prevent inadvertent alteration of the
model. These cells either require no data entry or contain equations.
Results will be presented in the highlighted cells when sufficient data have
been entered in the nonhighlighted cells to allow the models to complete
the calculations. Provisions have not been made in the models for
accumulating total medical costs within an institution for either
telemedicine or conventional health care. The following types of
information should not be entered into the models: costs common to both
telemedicine and conventional health care (e.g., medical records update
and maintenance) and costs for those conventional medical practices not
addressed by telemedicine (e.g., invasive medical procedures).

Simplified Cost Estimation Model 

The Simplified Cost Estimation Model is presented in figure C-1. The
model is divided into the following categories and subcategories.

 o Costs incurred by telemedicine.

    - Capital cost.
    - Operating cost.
    - Medical personnel cost.

 o Costs avoided by telemedicine.

    - Medical personnel cost.
    - Patient escort and transportation cost.

 o Other telemedicine system uses.

 o Telemedicine costs and benefits.

Costs incurred by telemedicine 

These are costs for acquiring and placing in service all capital assets, the
cost of operating and maintaining the telemedicine system, and the cost of
medical services.

Capital cost. The total cost of each capital asset is to be entered in the cells
provided. Suggested values for the service life of each asset have been
entered; however, you can change these if desired by overwriting the cell
values. The model will calculate the total capital cost, as well as the cost
per year. Straight-line depreciation, without salvage value, is assumed.

 o Installation. Enter the cost of all modifications and improvements
needed to prepare the facility telemedicine room. Some facilities may
require no changes, while others may require extensive changes. (Refer to
the worksheet in the detailed cost model for an explanation or breakdown
of costs if more information is needed.)

 o Telemedicine system. Enter the acquisition cost of the telemedicine
system, assuming that it is purchased and installed as an integrated system.
Otherwise, enter the total cost of all equipment, plus the labor cost of
integration. Include the cost of installing and testing the telemedicine
system.

 o Network/communications equipment. Enter the cost of any equipment
required to connect your telemedicine system with your communications
services provider. Examples of equipment in this category include inverse
multiplexers, fiber-optic converters, and communication cables.

 o Telemedicine room fixtures. Enter the cost of everything needed in the
telemedicine room, except the telemedicine system itself. Examples
include table, chairs, telephone, fax machine, and file cabinet.

 o Training. Enter the cost of training operations and maintenance
personnel as well as medical staff. As a rule, the telemedicine system
supplier provides training on operating and maintaining the equipment.
Training may also be required for medical personnel who present the
patient (inmate) to the physician during the telemedicine consultation. The
training considered here is the one-time initial training for starting the
telemedicine project; as such, it is a capital cost. Training conducted in the
future, as part of the day-to-day operations, would be an operating cost.

Operating cost. The operating cost includes all expenses associated with
running the telemedicine system.

 o Telemedicine system operation. Enter the cost per month of
maintaining the telemedicine room (but not the telemedicine system).
Note: The hours per month of telemedicine system operation, which is not
used in the calculations, will be automatically computed and is the same as
the hours per month of communications.

 o Communications. Enter the cost of all communications unique to the
telemedicine system. (Refer to the telemedicine operating cost spreadsheet
in the detailed model for an example of the types of costs to include.) The
hours per month of communications is calculated based on the minutes per
consultation and the number of consultations entered in the medical
personnel cost section (see below). It is for information purposes only and
is not used in calculating the communications cost.

 o Maintenance/support. Enter all costs associated with maintaining the
telemedicine system in good working order. This includes labor for
troubleshooting and repair, spare parts, and any items needed for periodic
maintenance. If you purchase a maintenance contract, enter the cost of the
contract.

Medical personnel cost. The cost of the medical staff involved with
telemedicine is entered in this section. The cost entered must be carefully
considered to achieve an accurate comparison with the cost of
conventional care. For each medical specialty to be practiced using
telemedicine, enter the number of consultations per year and the cost per
consultation. Also, enter the time (in minutes) that each consultation is
expected to take.

Once you have entered all the information requested above, the model will
calculate the total cost per year incurred by telemedicine.

Costs avoided by telemedicine 

Medical personnel cost. Enter the cost of medical staff that would have
been incurred in the absence of telemedicine. This cost may be either for
staff salary or for payment of medical fees to contract service providers.
For each type of consultation shown, enter the number of consultations per
year that telemedicine replaced and the cost of each consultation. The cost
per consultation includes both the physician's cost and the cost of any
other staff members needed to accompany or assist the physician.

 o Internal consultations. Enter the cost of medical consultations for
which, in the absence of telemedicine, a physician would have provided
medical care within the institution.

 o External consultations. Enter the cost of treatments patients would have
received at a nearby medical facility in the absence of telemedicine.

 o Medical center consultations. Enter the cost of treatments patients
would have received at a medical center located a considerable distance
from the institution. Remember that in such cases, the patient usually
remains at the medical center, perhaps for an extended period of time.

Patient escort and transport cost. Enter the cost that would have been
incurred in escorting and transporting a patient, either inside or outside the
institution, for medical care. The labor costs include all institution staff
involved in the escort or transport. The transport costs include all nonlabor
costs that would have been incurred in the escort or transport. Enter cost
data for the internal, external, and medical center consultations. Note that
the information to be entered here is the number of escorts or transports
avoided, which is not the same as the number of medical consultations.

Other telemedicine system uses 

If the telemedicine system is to be used for purposes other than providing
medical services, an appropriate credit should be made against the
telemedicine system capital and support cost. Based on the hours per
month of other uses, the model will calculate the cost per year for the other
uses and for the cost savings to be credited to telemedicine.

Telemedicine costs and benefits 

Once you have entered all the information requested above, the model will
calculate the costs and benefits, as well as other information that may be
useful when considering telemedicine acquisition.

Detailed Cost Estimation Model 

The concept for the detailed cost estimation model is the same as that for
the simplified model. The model is organized with the summary sheet
listed first and the more detailed sheets following, as shown in figures C-
2a through C-2h. Entry of data proceeds from the last sheet forward. This
format was chosen to allow management to review the results starting at
the top and working toward the more detailed information.

Telemedicine cost-benefit summary 

The Telemedicine Cost-Benefit Summary (figure C-2a) is identical to that
used for the simplified cost estimation model. However, in this case, all
information is calculated from data entered on the detail sheets. Only the
hours per month for other uses of the telemedicine system (as described
previously) need to be entered.

Capital cost

The Capital Costs sheet (figure C-2b) can be used alone or in conjunction
with the Telemedicine Installation Worksheet (figure C-2g) or the
Telemedicine Equipment Worksheet (figure C-2h) or both. If you are
using the electronic version, data entered on either of these worksheets
will automatically be transferred to the Capital Costs sheet. The worksheet
calculates the amortization (depreciation) of all capital assets. Straight-line
depreciation is used; however, if another method is desired, Excel offers
several alternative means of calculating depreciation.

Telemedicine operating costs 

The Telemedicine Operating Costs sheet (figure C-2c) is used to
accumulate all costs to operate and maintain the telemedicine system,
except for the cost of medical personnel.

Telemedicine system operating cost. This is the cost of the supplies and
personnel services needed to operate the telemedicine room. To maintain
accurate cost information for calculating costs and benefits, a consistent
approach should be followed for cost entry here and on the Medical Costs
Avoided by Telemedicine sheet (figure C-2e). Either one of the following
approaches is satisfactory:

 o Enter all costs for maintaining the telemedicine room. On the Medical
Costs Avoided by Telemedicine sheet, enter in the Other Cost column the
savings that accrue by replacing conventional care with telemedicine.

 o Enter only those costs that are unique to telemedicine.

Communications cost. Space is provided in figure C-2c to enter all
communications costs. However, the comments made above for cost entry
also apply here. The data and video communications cost should be
calculated accurately because it will be the largest operating cost item.
Depending on the communications protocol you are using and your
service provider, your data and video communications cost could be based
on rate per minute per line, rate per minute for your selected bandwidth,
rate per data packet (with or without a fixed monthly cost), or some
combination of these rates. The model includes a contingency factor of 20
percent for estimating the cost of communications.

Maintenance and support costs. This is the cost for maintaining the
telemedicine and communications equipment. If you have a fixed-cost
support subcontract, enter the cost of that contract in the Other Cost
column (figure C-2c). If you are providing maintenance, enter your labor,
parts, and other support costs in the spaces provided.

Medical personnel costs 

The Medical Personnel Costs sheet (figure C-2d) is used to calculate the
cost for all personnel who provide medical services. Medical personnel
should be listed by their specialty. Provisions are made for entering cost
data for consultations where the cost is determined either on an hourly
basis or on a per-consultation basis. The Consult (Minutes) column must
be filled in for both cost methods. Note that the total consultation minutes
per year are calculated for each physician on the basis of the Consult
(Minutes) column entry. The total consultation time for all physicians is
used to calculate communications costs.

Medical costs avoided by telemedicine

Theoretically, for each consultation performed through telemedicine, the
cost of a conventional consultation should be avoided. You should review
medical records for the past year and determine which patients could have
been cared for through telemedicine. This will form the basis for
establishing the number of telemedicine consultations that would have
occurred over the same time period, as well as the number of internal,
local external, and medical center consultations that could have been
avoided through telemedicine. The medical specialties involved and your
cost to provide these specialty services should be entered in the
appropriate locations.

One of the most difficult tasks will be to establish an accurate count of
external and medical center consultations avoided through telemedicine. If
telemedicine provides better access to medical services or access to
medical specialties that were otherwise not available, you may find that
the more immediate treatments enabled by telemedicine reduce the
incidents requiring transport of a patient for outside medical services.
(Review the findings of the telemedicine demonstration project at
http://www.ncjrs.org/telemedicine/toc.html for guidance.)

Medical escort and transport costs avoided 

The Medical Escort and Transport Costs Avoided sheet (figure C-2f) is
used to calculate the cost avoided because patients treated through
telemedicine did not require escort or transport. The cost categories list
personnel normally involved in escorting or transporting patients. For
external and medical center consultations, provisions are made to enter the
cost to provide the transportation.

For internal medical consultations, escort costs may be avoided if the
escort provided is part of the routine movement of inmates. For external
and medical center consultations, enter the cost for planning, preparing
paperwork, coordinating with the outside facility, and transporting the
patient; travel time to and from the destination, time spent at the
destination, and time for closing the incident; and all transportation costs. 

Telemedicine installation worksheet 

The Telemedicine Installation Worksheet (figure C-2g) provides
additional space for entering cost data for installing the telemedicine
system. No entries are required on this worksheet if all installation costs
were entered on the Capital Costs sheet. Cost information entered on the
Telemedicine Installation Worksheet will be automatically transferred to
the Capital Costs sheet if you are using the electronic version.

Telemedicine equipment worksheet 

The Telemedicine Equipment Worksheet (figure C-2h) provides additional
space for entering cost data for procuring the telemedicine equipment. No
entries are required on this worksheet if all equipment costs were entered
on the Capital Costs sheet. Cost information entered on the Telemedicine
Equipment Worksheet will be automatically transferred to the Capital
Costs sheet if you are using the electronic version.

------------------------------

Appendix D

Medical Requirements Analysis Worksheet

Medical Requirements Analysis 

Construct a form or worksheet to collect the information outlined below.
Information should be gathered for external outpatient consultation,
external inpatient consultation, and internal consultation. This information
should be gathered for each subspecialty, such as dermatology,
orthopedics, or cardiology. 

 o The number of routine consultations.

 o The number of emergency consultations.

 o Frequency of consultations (patients seen per month).

 o Locations consultations are conducted.

 o Monthly costs.

 o Number of consultations appropriate for telemedicine (case examples).

 o Time required for consultations.

 o Total monthly time required for consultations.

 o Type of data used.

    - Static or dynamic images, textual.
    - Source of data (x-ray, EKG strip, etc.).
    - How often will data be produced?
    - How often will data be recalled for later use?
    - How often will data be communicated to a remote location?
    - How many locations?
    - Expectations of data (image quality, annotations).
    - Format of data for presentation (color, printed, viewed).
    - Response time for data (prison-telecom-hospital).

 o Equipment used for consultations.

 o Number of inmates on waiting list.

 o Factors causing wait list.

 o Current practices and procedures for medical consultation.

------------------------------

Appendix E

Medical Requirements Analysis--Clinic Survey Form

Medical Requirements Analysis--Clinic Survey Form 

For planning purposes, responses to the following questions should be
gathered from the clinics.

A. What telemedicine clinics would you like to see scheduled at your
facility? Please specify any other clinics that are not listed below:

Psychiatry
Dermatology
Orthopedics
Podiatry
Cardiology

B. What specialty areas would you like to have available for nonclinic
consultations (nonemergency)?

C. How quickly would you need to have the nonclinic consultations
(nonemergency)?

All specialty areas have the same response time, or the maximum response
time varies by specialty area.

D. What turnaround time is required for teleradiology consultations for
plain films?

Initially, would a faxed consultation report meet your needs?

How soon should the hardcopy consultation report follow?

E. Is the number of plain films you indicated equal to the number of
monthly teleradiology consultations, or is the number of monthly
consultations less than this number? In other words, how many monthly
teleradiology consultations do you project and how many monthly films
do you project?

------------------------------

Appendix F

Position Description--Telemedicine Coordinator

Introduction

The incumbent serves as the telemedicine coordinator at a prison remote
telemedicine site. Services are coordinated in collaboration with the off-
site telemedicine consultant and the prison staff. The telemedicine
coordinator is primarily responsible for coordinating telemedicine
operations and medical consultations and for providing training and
assistance for the prison medical staff.

Major Duties

 o Serves as the telemedicine coordinator at a remote prison telemedicine
site.

 o Coordinates and schedules subspecialty consultations (clinic and
nonclinic) for inmate medical care with the telemedicine consultants.
Operates telemedicine equipment during telemedicine consultations (as
appropriate) and helps the presenter use the telemedicine equipment
during the telemedicine consultation.

 o Assembles patient consultation forms and medical records for faxing or
mailing to telemedicine consultant before the scheduled subspecialty
clinics. Reviews information in advance to ensure completeness and
legibility.

 o Collects and reports required patient evaluation data on a timely basis.

 o Ensures telemedicine equipment is fully operational and maintained
and is properly set up and tested before scheduled consultations.

 o Maintains stock of supplies and ensures security of the exam room and
equipment.

 o Provides reports and status updates as required.

 o Provides input for developing telemedicine policy and procedure.

 o Teaches other health care personnel to operate and maintain the
telemedicine equipment.

 o Works responsibly and cooperatively with entire telemedicine team.

 o Ensures patients' privacy and confidentiality.

 o Performs related duties as required, but accepts only those duties that
are commensurate with educational preparation, training, experience, and
licensing laws.

 o Adheres to all infection-control policies and procedures.

 o Is subject to prison security background check, which is to include
urinalysis drug screen.

Knowledge Required 

 o Working knowledge of medical theory, clinical practice and patient
care, and medical terminology.

 o Working knowledge of the use of computers, associated software
applications, office equipment, and medical equipment (e.g., stethoscope).

 o Excellent interpersonal skills.

 o Ability to understand medical records and accurately extract and enter
patient data from patient encounters.

 o Familiarity with prison custody, safety, and security regulations; health
service policies and procedures; and inmate behavior. 

 o Ability to train other health care staff to operate and maintain the
telemedicine equipment.

 o Knowledgeable in the legal and ethical aspects of correctional
medicine.

Supervisory Controls

The position is supervised by the head of Health Services. However, the
incumbent performs effectively and independently. The incumbent will
have the ability to set priorities, to be organized, and to determine when to
seek appropriate assistance. The prison warden will have ultimate
authority and responsibility for all telemedicine activities and efforts at the
prison remote site. The incumbent will be guided by the needs of the
prison in all tasks performed.

Physical Demands 

This position may require long periods of standing or sitting. The
incumbent is required to lift and move supplies and to use specific medical
equipment. The incumbent must be able to function under stressful
circumstances and be capable of coping with complex or rapidly changing
situations.

Work Environment 

The incumbent works in a hazardous-duty environment in a correctional
setting. In addition, this individual is subject to all exposures common to
the health care setting, including infectious and communicable diseases,
irritant chemicals, and electrical hazards. The incumbent does not provide
direct patient care.

------------------------------

Appendix G

Developing Telemedicine Procedures

A successful telemedicine consult requires the consultant physician or
other health care provider to be thoroughly prepared. Before the consult,
the originating provider should review and collect information relevant to
the consultation. The health care provider should have established
procedures for collecting information for telemedicine consultations.

This publication does not identify and develop procedures for all specialty
requirements. Rather it presents guidance on how to develop procedures
that can be used to conduct telemedicine consultations.

Any procedures developed must be consistent with acceptable medical
practices. Competent medical personnel must review the procedures on a
regular basis.

Procedures should be developed for various medical specialties that
require different information and different preparation. A cardiology
consult may require information on recent stress tests, for example, while
a dermatology clinic may require the results of specified lab tests.
Procedures for dermatology consults can be established by asking the
consulting dermatologist for the information necessary to conduct a
telemedicine consult. With guidance from the consulting dermatologist, a
written procedure can be designed to be used during a dermatology
consult. The same process can be used to create procedures for other
medical specialties.

Any information the provider would have available for an in-office patient
should be provided to the telemedicine consultant. The patient's medical
record and any relevant tests or laboratory results must be available. In
some cases, this information must be transmitted to the consulting
physician before the consult.

State medical boards may be able to provide information on State laws and
regulations pertaining to telemedicine. The boards of specific medical
specialties may also be helpful, as may other correctional agencies that
have established telemedicine programs. For example, the Federal prison
system has an established telemedicine program and procedures for
conducting telemedicine consults. For copies of its procedures, contact--

Assistant Director
Health Services Division
Federal Bureau of Prisons
320 First Street N.W.
Washington, DC 20534
http://www.bop.gov

Other contacts that may be helpful in developing procedures for
conducting a telemedicine consult include--

National Commission on Correctional Health Care
1300 West Belmont Avenue
Chicago, IL 60651
http://www.ncchc.org

American Telemedicine Association
910 17th Street N.W.
Suite 314
Washington, DC 20006
http://www.atmeda.org

------------------------------

Appendix H

Glossary of Telemedicine Terms

ACR-NEMA. American College of Radiology and National Equipment
Manufacturers Association. These organizations have jointly developed
standards for teleradiology practice. For computed tomography (CT),
magnetic resonance imaging (MRI), ultrasound, nuclear medicine, and
digital fluoroscopy, images must be scanned at a resolution of 500 pixels x
500 lines at a depth of 8 bits (256 gray scale) or better; for diagnostic x-
rays, 2,000 pixels x 2,000 lines ("2k by 2k") at 12 bits (4,096 gray scale).

ADSL. Asymmetric digital subscriber line. A system currently under trial
in several metropolitan areas. Uses existing copper phone lines. With
proper retooling by telephone companies, ADSL can supply 6-Mbps
downstream delivery of data. 

algorithm. A mathematical coding scheme. A coding scheme can
compress digitized broadband video or audio signals so that the signals
can be transmitted over a lower (and less expensive) bandwidth.
Standards-based algorithms enable communications with standards-based
systems from disparate manufacturers. Proprietary algorithms are unique
to individual manufacturers and enable communications only between
equipment from that manufacturer. Current practice strongly encourages
standards-based systems.

analog. Information (electronic or otherwise) that is created and
transmitted as a continuous stream. Waveforms (e.g., on oscilloscopes) are
analog. Compare this to digital information generated by computers.
Modems are used to convert digital computer data to analog form for
sending over standard (plain old telephone system, POTS) lines.

annotation. The capability to add comments or highlights to captured or
live video. Simultaneous shared annotation of captured (or, less
commonly, live video) images allows conference participants to clearly
point out the areas in question on an image, and may provide significant
instructional value.

ATM. Asynchronous transfer mode. A telecommunications service that
supports switched multimedia communications from T1 (1.544 Mbps) to
very high data rates (155 Mbps and higher). Not commonly available.

audio-only conference add-ins. The capability to add another site into a
videoconference using only an audio connection. This feature uses a
regular phone line connected to the CODEC to connect someone who is
not near a video site but needs to be part of the conversation.

bandwidth. The capacity of an electronic transmission medium to transmit
data per unit of time. The higher the bandwidth, the more data can be
transmitted. Typically measured in kilobits or megabits per second.
Standard telephones are low-bandwidth devices (a maximum bandwidth of
33.6 Kbps). Cable television uses high bandwidth (up to 140 Mbps).

beam splitter. A device for tele-otoscopes or -ophthalmoscopes that allows
the clinician to see directly into the eye or ear and also routes a portion of
the image to the video camera. This capability is usually preferred by the
clinician, who is accustomed to looking directly through the device rather
than at a video monitor.

bit. Binary digit. The basic 0-1 unit of information used by computers for
information entry, storage, and transmission. Data rates in
telecommunications are often referred to in bits (b) per second. See
bandwidth, byte, Kbps, Mbps.

BRI. Basic rate interface.

bursty data. Short, intense transmissions of grouped, related information.
Sometimes called "boluses of data" by medical clinicians. 

byte. The amount of computer memory needed to store one character.
Each data character, such as the letter A, is composed of 8 bits, called a
byte (abbreviated B). Units of storage are often referred to in terms of the
number of bytes (e.g., "100-MB hard drive").

camera control. The capability to control the video camera used in the
consultation, either at the near end (local control of local pan-tilt-zoom
iris-focus) or the far end (hub control of pan-tilt-zoom at the remote site).
This feature may be quite useful in consultations if the examiner wants to
control the remote camera's view without having to provide verbal
directions to the assistant at the remote site.

CCD. Charge-coupled device. An integrated circuit, or "chip." A 1-CCD
(one-chip) camera contains a single charge-coupled device with
specialized semiconductors containing photosensitive cells that generate
voltage when struck by photons of light. One photosensitive cell equates
to one pixel in the displayed image. The number of cells on a chip
determines the number of pixels of resolution that the camera can display.
The larger the chip, the greater the image resolution. Increased resolution
is accomplished either by using larger chips or by using more chips.
Single-chip cameras do a good job. Two-chip cameras use one chip for
chrominance and one for luminence. Three-chip cameras do an even better
job, because they have more total cells and because they use one chip each
to capture red, green, and blue light. Three-chip cameras provide images
with higher resolution and better color representation, and can cost 10
times as much as single-chip cameras. CCD scanners for teleradiology are
less expensive than laser scanners and may not have the same ability to
detect contrast. This may or may not affect their ability to transmit
diagnostic-quality images.

chip. An integrated circuit. See CCD.

chrominance. Hue and saturation (color) on a video monitor. 

CIF. Common intermediate format. An international standard for video
display formats developed by the TSS (see ITU-T Standards). 

CODEC. Coder/decoder hardware or software used with interactive video
systems that converts an analog signal to digital, then compresses it so that
lower bandwidth telecommunications lines can be used. The signal is
decompressed and converted back to analog output by a compatible
CODEC at the receiving end. The compression method (algorithm) may
be proprietary or standards based.

CSU/DSU. Channel service unit/data service unit. A hardware device that
is needed to terminate a high-speed telecommunications connection. It is
inserted between the telemedicine system (e.g., CODEC) and the
communications line. The device conditions and strengthens the signal and
supports the necessary link protocols for transmission of data over leased
or switched communications lines. It also acts as a multiplexer.

DICOM. Digital imaging and communications in medicine. An industry
standard for connection of, and communications among, medical imaging
devices. The most recent iteration is DICOM 3.

digital. Information coded in discrete numerical values (bits). Digital data
streams are less susceptible to interference than analog data streams. Also,
because they are made up of zeros and ones (bits), they can be
manipulated and integrated easily with other data streams (voice, video,
data).

digital camera. A camera that captures images (still or motion) digitally
and does not require analog-to-digital conversion before the image can be
transmitted or stored in a computer. The analog-to-digital conversion
process (which takes place in a CODEC) usually causes some degradation
of the image and a time delay in transmission. Avoiding this step
theoretically provides a better, faster image at the receiving end.

DS3. A leased line (nonswitched) running at 45 Mbps. Compare with
OC3, T1, ISDN.

duplex audio. A communications mode that enables simultaneous
transmission and reception of audio signals in both directions. Full-duplex
audio enables both ends of a conference to speak and be heard
simultaneously (like a regular telephone call). Half-duplex audio supports
only one site speaking at a time; other speakers will be cut off.

echo cancellation. A feature that prevents a system from picking up the
sound from its own speakers and transmitting it back to other conference
sites. Highly desirable for acceptable audioconferencing. 

encryption. A security feature that ensures that only the parties who are
supposed to be participating in a video conference or data transfer are able
to do so. It is accomplished by mathematically transposing a file or data
stream so that it cannot be deciphered at the receiving end without the
proper key.

Ethernet. A local area network datalink protocol operating at 10 Mbps to
100 Mbps.

firewall. A computer connected to both the Internet and the local hospital
information network that prevents the passing of Internet traffic to the
internal hospital network. It provides an added layer of protection against
computer hackers.

fps. Frames per second. See frame rate.

frame rate. The number of frames per second (fps) displayed on a video
monitor. A frame rate of 25-30 fps is considered "full motion"; most
broadcast video operates at this rate. A frame rate of 15 fps is noticeably
"jerky." Slower frame rates may be inadequate for observing and
analyzing gait and motion.

frame relay. A service that supports data rates in the range of 56 Kbps to
1.54 Mbps. The frame relay circuit often comes in different levels of
committed information rates. Regional telephone companies can offer
frame relay cheaper because they can oversubscribe these circuits to users
and share the bandwidth.

freeze-frame video. A video camera feature that allows the consultant to
get a well-framed and focused still image of a lesion or other medical
condition for closer examination. Still images captured from a live video
source are often of higher resolution than the live video picture and, as a
result, may provide more diagnostic value. Also referred to as image
capture.

frequency response. A relative measure of audio quality, expressed in
cycles per second, or hertz (Hz). Generally, the broader the frequency
response, the better the signal. To approximate a standard acoustic
stethoscope, an electronic stethoscope should be able to send and receive
sounds as low as 30 Hz (for low-pitched heart murmurs) and as high as
1,000 Hz (for squeaks, wheezes, and pops heard in lung conditions). Many
electronic stethoscopes can have their frequency response optimized for
either heart or lung sounds by flipping a switch.

full-motion video. Video that runs at 25 or 30 frames per second, down to
a minimum of 10-15 fps. Any frame rate less than about 10 fps is
approaching slow-scan video.

ghosting. A motion artifact in monitor displays of compressed video
images. As an image moves quickly across the field of view (e.g., an arm
waving), it leaves a trail of ghost images that resolve as the movement
stops.

graphic equalizer. A device that allows the user to emphasize or
deemphasize selected frequencies within an audio sample. An example is
the different settings for heart and lung sounds in electronic stethoscopes.
See frequency response.

graphics stand. A device that is typically used to support a document so
that images of graphics or text can be captured and transmitted. Can be
used for skin lesions and the like.

gray scale. The levels (shades) of gray that a screen or pixel within a
screen can display. 

GUI. Graphical user interface. See interface.

H.230, H.242, H.256, H.263, H.324, . . . . See ITU-T Standards, video
format.

IATV. Interactive televideo. Also abbreviated ITV.

image capture. See freeze-frame video.

image management. The capability to sort, arrange, and manipulate stored
images into functional groups. Systems without this feature allow the user
to store images only in the order in which they were saved; once stored,
they cannot be rearranged.

INMARSAT. An international global telecommunications satellite
network, established by government treaty in 1979, with 79 member
countries. Land Earth Stations (fixed or portable, even to size) provide
links between rural sites and telecommunications networks. INMARSAT
can provide low-bandwidth digital services anywhere on the Earth's
surface for as little as $1 per minute.

integrator. A vendor that uses parts from other manufacturers to produce a
product that is optimal for the particular user's requirements.

interface. The means whereby a system enables information to be accessed
and modified. A graphical user interface with mouse-controlled, point-
and-click on-screen icons is an example of an easy-to-use interface device.

ISDN. Integrated services digital network. A low- to medium-speed
technology for digital telephony. Usually transmits at 64-128 Kbps,
although higher speeds are possible.

ISO. International Organization for Standardization. The ISO, in
conjunction with the International Electrotechnical Commission,
establishes and coordinates worldwide standards for, among other things,
electronic information exchange. 

ISP. Internet service provider. The local, regional, or national company
that provides dial-up connections to the Internet, as well as hosting of
home pages.

ITU-T. International Telecommunications Union-Telecommunications
Standardization Sector (TSS). An organization founded in 1865 as a
telegraphy standards body and now is a United Nations agency. 

ITU-T Standards. The H series refers to videoconferencing standards; the
G series, to audioconferencing standards; and the T series, to data transfer
standards. The T.120 series, in particular, refers to image capture,
annotation, and transfer in videoconferences.

ITV. Interactive televideo. Also abbreviated IATV.

JPEG. Joint Photographic Experts Group. The international group that has
developed standards for still-image compression.

KB. Kilobyte. 1,024 bits of data.

Kbps. Kilobits (thousands of bits) per second. A typical compressed-video
clinical interaction is transmitted at 385 Kbps.

LAN. Local area network. A computer network linking computers,
printers, servers, and other equipment within an organization.

laser digitizer. A scanner that uses a laser device to capture image
information in digital form. Very high resolution and wide gray-scale
range are possible.

leased line. A point-to-point private line for the sole use of the party who
leases the circuit. Unlike a switched line, the price of a leased line does not
vary as a function of usage.

leveling. A software manipulation technique, using mathematical
algorithms, to compensate for a teleradiology monitor's inability to
provide the same contrast and bit depth as the original hardcopy x-ray.
This feature provides much more usable clinical information.

low-pass filter. A filter for leveling out the borders in the screen display of
a radiology image.

luminence. Characteristics of brightness for a video monitor.

MB. Megabytes (millions of bytes).

Mbps. Megabits (millions of bits) per second. A typical uncompressed
video signal requires 45 Mbps (or more) to transmit.

modem. Modulator-demodulator. A device that enables transmission of
digital data (by transforming it to and from analog waveforms) over
standard analog phone lines and cable video systems.

MPEG. Moving Picture Experts Group. A group of standards for
compressing and storing motion video.

MRI. Magnetic resonance imaging.

multiplexer. A hardware device that combines two or more subchannels of
information for transmission as a single data stream.

MUX. Multiplexer.

network. An assortment of electronic devices (computers, printers,
scanners, etc.) connected (by wires or wireless) for mutual exchange of
digital information. 

ocular tube adapter. A device that allows a camera to be mounted to any
microscope. This feature is needed to adapt a telepathology system to an
existing ocular microscope without a camera port. Capturing images
through an ocular tube has some disadvantages that must be weighed
against the cost of a new scope.

OC3. A high-speed digital transmission capability of 1.55 Mbps. Compare
with DS3, T1, ISDN.

PBX. Private branch exchange. A telephone switch, typically located at
the customer site, connected to the public telephone network but operated
by the customer. PBXs may be digital or analog.

peripheral device. An attachment to a videoconferencing system to
augment its communications or medical capabilities. Examples include
electronic stethoscopes, otoscopes, ophthalmoscopes, dermascopes,
graphic stands, and scanners.

PIP. Picture in picture. This feature allows both ends of the
videoconference to be viewed simultaneously on a single monitor. PIP
swap allows the user to switch the two video pictures so that the local
video fills the largest portion of the screen.

pixel. The smallest unit of a raster display; a picture cell with specific
color or brightness. The more pixels an image has, the more detail, or
resolution, it can display.

POTS. Plain old telephone system. The analog, public switched telephone
network in common use throughout the world. POTS enables voice phone
calls and data transmission of up to 56 Kbps, as well as limited
videoconferencing.

PRI. Primary rate interface.

primary user interface device. The device used to control the
videoconferencing system. Hardwired and wireless, keyboard, mouse, and
touchscreen options each have advantages and disadvantages. The user
should seriously consider in what setting and for what application the
system will be used to determine the preferred interface.

printer interface. A device that allows data and images sent or received via
the computer to be sent to a printer. This enables reports, images, and data
shared in a videoconference to be rendered as hardcopy for recordkeeping
and teaching purposes.

raster. A pattern of scanning lines covering the area upon which the image
is projected in the cathode ray tube of a television set.

real time. Transmission and reception of audio, video, and data virtually
simultaneously (without more than a fraction of a second delay).
Applications that are transmitted within a few seconds are sometimes
called "near" real time. Compare with store-and-forward, slow-scan video.

resolution. The level of detail that can be captured or displayed. For video
displays (teleradiology or interactive video), resolution is measured in
pixels x lines x bit depth.

RGB. Red green blue. A coding language that controls the electron gun in
cathode ray tube monitors. The video signal that enters the monitor is
separated into its component parts and converted to RGB; the video
images are then rendered on the monitor's screen.

rollabout unit. A portable teleconferencing or telemedicine system in
which the monitor, CODEC, camera, etc., are placed in a cabinet with
wheels that can be rolled from room to room. "Rollabout" can be a
misleading term, because some units weigh more than 500 pounds and are
very cumbersome to move.

room unit. A stationary teleconferencing or telemedicine system, usually
with two large monitors, that is placed more or less permanently at a
single site.

RS-232. An interface between data terminal equipment and data
communications equipment, using serial binary data exchange.

scan line. Raster.

slow-scan video. A slow progression of freeze-frames (less than 1 or 2 per
second). Also called "still video." Compare with full-motion video.

spooling. The capability to review one image or data set, while receiving
and storing additional images for subsequent review without "locking up"
the computer.

store-and-forward. Captured audio clips, video clips, still images, or data
that are transmitted or received at a later time (sometimes no more than a
minute later). Compare with real time.

switched line or network. A telecommunications mode similar to a dial-up
telephone line. There is often a usage charge for switched services,
particularly for long-distance connections, such as telephone lines.
Compare with leased line, where the connection is continuously open and
charges are usually levied at a flat, monthly rate.

Switched 56. A dial-up 56-Kbps digital line, billed at a monthly rate plus a
per-minute charge, as with a POTS phone line. Costs for switched 56
service vary from provider to provider, but generally are about the same or
somewhat more than those of a voice call.

T1. A leased line providing 1.544-Mbps data. T1 is available almost
everywhere and can be fractionated. Fractional T1 services are less
expensive than full T1. Typical interactive video telemedicine programs
transmit video images at "1/4 T1" rates (384 Kbps).

T.120. A standard for audio and graphics exchanges, supporting higher
resolutions and pointing and annotation (which the H.320 standard does
not).

tariff. Telecommunications rates set by either a Federal or State regulatory
body.

TCP/IP. Transmission control protocol/Internet protocol. The most
popular open-standard protocols used in data networks today. The Internet
protocol is used to route packets of data on a network.

telemedicine. The provision of health care over a distance using
telecommunications technology.

teleradiology. The interpretation of diagnostic images sent over a distance
using leased or switched transmission lines.

third-party equipment. Equipment added to an existing system to expand
the original system's capabilities. Some vendors modify videoconferencing
systems with additional cameras to fabricate a telemedicine capability.
Third-party equipment may not be covered by the vendor's warranty, and
its performance may not be guaranteed.

transmission rate. The amount of information per unit of time that a
technology such as a conventional (POTS) or digital (ISDN or T1)
telephone line, satellite or wireless telecommunications, or LAN can
transmit. A typical POTS-based modem can transmit 33.6 Kbps of
information per second.

TSS. Telecommunications Standardization Sector of the International
Telecommunications Union. See ITU-T.

twisted pair. A pair of copper wires that has been twisted to minimize
electronic interference. Standard telephone wire.

URL. Universal resource locator. The World Wide Web address (typically
in the form: http://www.name_of_site) of an Internet home page or other
document.

video format. The manner by which video images are exchanged between
the remote and hub sites. Formats include National Television System
Committee (NTSC), phase alternation line (PAL), high-definition
television (HDTV), and sequential color and memory (SECAM).

video on demand. The ability to provide instantaneous access to remotely
stored sources of video.

video output. Composite, S-video.

videophone. A small, standalone video appliance with a small camera and
circulation--not part of a computer or larger videoconferencing system--
that enables interactive audio-video communications over POTS and
ISDN.

WAN. Wide area network. A computer network wider in geographic scope
than a LAN. Provides digital communications (voice, video, data) over
switched (ISDN, switched 56) or unswitched (fractional T1, T1) networks.

------------------------------

About the National Institute of Justice

NIJ is the research and development agency of the U.S. Department of
Justice and is the only Federal agency solely dedicated to researching
crime control and justice issues. NIJ provides objective, independent,
nonpartisan, evidence-based knowledge and tools to meet the challenges
of crime and justice, particularly at the State and local levels. NIJ's
principal authorities are derived from the Omnibus Crime Control and
Safe Streets Act of 1968, as amended (42 U.S.C. sections 3721-3722).

NIJ's Mission

In partnership with others, NIJ's mission is to prevent and reduce crime,
improve law enforcement and the administration of justice, and promote
public safety. By applying the disciplines of the social and physical
sciences, NIJ--

 o Researches the nature and impact of crime and delinquency.

 o Develops applied technologies, standards, and tools for criminal justice
practitioners.

 o Evaluates existing programs and responses to crime.

 o Tests innovative concepts and program models in the field.

 o Assists policymakers, program partners, and justice agencies.

 o Disseminates knowledge to many audiences.

NIJ's Strategic Direction and Program Areas

NIJ is committed to five challenges as part of its strategic plan: 1)
rethinking justice and the processes that create just communities; 2)
understanding the nexus between social conditions and crime; 3) breaking
the cycle of crime by testing research-based interventions; 4) creating the
tools and technologies that meet the needs of practitioners; and 5)
expanding horizons through interdisciplinary and international
perspectives. In addressing these strategic challenges, the Institute is
involved in the following program areas: crime control and prevention,
drugs and crime, justice systems and offender behavior, violence and
victimization, communications and information technologies, critical
incident response, investigative and forensic sciences (including DNA),
less-than-lethal technologies, officer protection, education and training
technologies, testing and standards, technology assistance to law
enforcement and corrections agencies, field testing of promising programs,
and international crime control. NIJ communicates its findings through
conferences and print and electronic media.

NIJ's Structure

The NIJ Director is appointed by the President and confirmed by the
Senate. The NIJ Director establishes the Institute's objectives, guided by
the priorities of the Office of Justice Programs, the U.S. Department of
Justice, and the needs of the field. NIJ actively solicits the views of
criminal justice and other professionals and researchers to inform its
search for the knowledge and tools to guide policy and practice.

NIJ has three operating units. The Office of Research and Evaluation
manages social science research and evaluation and crime mapping
research. The Office of Science and Technology manages technology
research and development, standards development, and technology
assistance to State and local law enforcement and corrections agencies.
The Office of Development and Communications manages field tests of
model programs, international research, and knowledge dissemination
programs. NIJ is a component of the Office of Justice Programs, which
also includes the Bureau of Justice Assistance, the Bureau of Justice
Statistics, the Office of Juvenile Justice and Delinquency Prevention, and
the Office for Victims of Crime. 

To find out more about the National Institute of Justice, please contact:

National Criminal Justice Reference Service
P.O. Box 6000
Rockville, MD 20849-6000
800-851-3420
e-mail: askncjrs@ncjrs.org

To obtain an electronic version of this document, access the NIJ Web site
(http://www.ojp.usdoj.gov/nij).

If you have questions, call or e-mail NCJRS.