International Journal of Telemedicine and Applications format. The group session would not only serve as a forum for patients with similar disease groups to interact with the specialist clinician, but would also serve as a supportive group atmosphere for patients to identify with each other. Quoting a provider with this idea: There are some patient education programs that could be incorporated, we currently have an education program for Hepatitis B and C patients, there are some types of liver diseases we could provide patient education programs ahead of time assisting patients in making decisions about pursuing an appointment with the specialist pri- marily for the treatments purposes versus being followed by the PCP. Due to the ﬁnancial premium of having a specialist conduct these sessions themselves and the time commitment involved, UCSF, SFGH, and DPH could identify interested qualiﬁed personnel within its already extensive resource of APN healthcare professionals and redeﬁne the role of the Advanced Practice Nurse, the Nurse Practitioner, Physician Assistant, Certiﬁed Nurse Leader, and the Certiﬁed Nurse Specialists. However such an approach based on task shifting would have to be contingent on the patient’s voice and the political buy-in and leadership support of the CNO as well as would require the necessary approvals from the organi- zational structures put in place by the Nursing Executive Committee (NEC) and the Committee on Interdisciplinary Practice (CIDP). Quoting providers with this idea, “There is a lot of potential here (with tel- emedicine) and the other question is that do you need doctor to do it . . . we have huge number of nurses who have advance training here in San Francisco general hospital, nurse leaders, nurse mangers, nurse specialists there are people who have advance educational training so should there be a physicians doing the education or should they be one of these advance practice nurses who does that . . . that depends upon what the patient wants and what the primary provides wants.” This type of telemedicine service based on education would focus on preparing the patient for the physical and mental rigors of presenting at the specialist appointment, in addition to self-care education focusing on lifestyle modiﬁ- cation, dietary and nutritional education, and education on managing chronic pain. Quoting another provider with this idea, “I have heard of a taskforce convened and they have started talking about Group visits for GI Patients and preparation for a colonoscopy could help and would also help increase access to care and assist in preparation in advance of the visit . . . a place to obtain the informed consent, with risk and beneﬁts to be explained as well as more 9 information from the specialist . . . This would be the initial visit . . . and all of this could be done in a group setting by either a specialist, but more importantly since it is education, Nurse practitioner, Physician Assistant or maybe even a Registered Nurse.” Key informant interviews with providers also revealed interest in educational activities focused on (chronic) disease management for HIV, diabetes, and asthma. Some quotes to illustrate this: “The core of our patient population are people who are or were homeless at some point, HIV inﬂicted, lots of mental illness and active substance use, multiple chronic conditions, chronic pain being one of those and people who in general have had very variable experiences with the health system in general.” “We have a more African American diabetic population, average number of hypertensive’s, higher number of HIV positive patients ranking third amongst ten, and take care a lot of kids . . . we are a very busy clinic within the system.” Educational sessions to prepare patients for the spe- cialist visit in areas of highest need included group liver sessions (hepatitis B, hepatitis C, viral hepatitis) and Group cardiology sessions (anticoagulation education, cardiology medication education, cardiac risk factor education, cardiac valve disease education) One providers view: “What would be neat is if we could do group visit stuﬀ with our patients, for example if we got 20 patients and if I connected remotely with some specialist services, so patients do not have to end up going to the general, they could just come here, and meet with me since they are already comfortable coming to the clinic here, Hepatitis C classes I believe is something they have talked about doing.” 8.4.3. Specialist to PCP and Patient Telemedicine. One of the key rationales for this type of clinical/diagnostic-based activity as a key service for the use of telemedicine technology was having patients who would otherwise not have adequate access to specialty care services at the hospital, due to their inability to physically travel to the hospital or generally lack in following up on PCP recommendations due to discomfort or unfamiliarity with the specialty care setting or for patients undergoing transitional issues between primary and acute care or specialty settings. Some quotes from providers below: Patients have a lot of questions and are emo- tionally distressed about the risk of a certain procedures, and as a PCP I do not have access to that type of information, which the patient would