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Item K11BOARD OF COUNTY COMMISSIONERS AGENDA ITEM SUMMARY Meeting Date: Wed., March 19, 2008 Bulk Item: Yes No XX Division: BOCC Department: Comm. Di Gennaro, District 4 Staff Contact Person: Tamara Lundstrom (305 289-6000) AGENDA ITEM WORDING: Approval of Resolution in. support of telemedicine utilizing advanced technology as a key tool to bring better health care and health education to Florida's rural communities. ITEM BACKGROUND: To encourage the State Legislature, through the FL Department of Health to fund a telemedicine pilot program with a state -funded University College of Medicine. As an example, Florida State University has six regional College of Medicine campuses, essential for a state-wide telemedicine program to effectively measure success in enhancing medical services for the rural communities across the state. PREVIOUS RELEVANT BOCC ACTION: CONTRACT/AGREEMENT CHANGES: STAFF RECOMMENDATIONS: TOTAL COST: BUDGETED: Yes No COST TO COUNTY: SOURCE OF FUNDS: REVENUE PRODUCING: Yes No AMOUNT PER MONTH Year APPROVED BY: County Atty OMB/Purchasing Risk Management _ DOCUMENTATION: Included XX Not Required DISPOSITION: Revised 2/05 AGENDA ITEM # Commissioner Di Gennaro RESOLUTION - 2008 A RESOLUTION OF THE BOARD OF COUNTY COMMISSIONERS OF MONROE COUNTY, FLORIDA IN SUPPORT OF TELEMEDICINE UTILIZING ADVANCED TECHNOLOGY AS A KEY TOOL TO BRING BETTER HEALTH CARE AND HEALTH EDUCATION TO FLORIDA'S RURAL COMMUNITIES. WHEREAS, telemedicine has been defined as the use of telecommunications to provide medical information and services; and WHEREAS, health information technology advances and innovations include electronic health records, computerized decision support systems, home health, and other technologies that store, protect, retrieve, and transfer clinical, administrative, and financial information electronically within health care settings; and WHEREAS, rural communities like .Monroe County are facing shortages in specialists, nurses, and mainland clinical care can be difficult for residents to access; and WHEREAS, telemedicine can expand access, increase coordination, and improve the quality of health care services; improve and expand the training of health care providers; and expand and improve the quality of health information available to health care providers, patients, and their families; and WHEREAS, telepathology (the sending of pathology slides electronically) can be utilized for diagnostic consultation, and teleradiology (the sending of x-rays, CT scans, or MRI's electronically) is a common application of telemedicine in use today; and WHEREAS, videoconferencing technology achieves interactive "real time" consultations from urban -to -rural hospitals and locations; and WHEREAS, almost all specialties of medicine have been found to be conducive to this kind of electronic inter -active consultation, including psychiatry, internal medicine, rehabilitation, cardiology, pediatrics, obstetrics, and gynecology and neurology; and WHEREAS, the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) has created the Office of Health Information Technology (OHIT) within the HRSA to promote health information technology advances and innovations; and WHEREAS, OHIT oversees the Telehealth Network Grant Program through the Office for the Advancement of Telehealth (OAT) in support of telehealth networks that provide services in different settings (e.g. long-term health eare'faeilities, hospitals, community health centers or clinics, physician offices, schools, assisted living facilities, etc.) to demonstrate how telehealth networks can be used, and has awarded over $250 million in grants to deploy electronic information and telecommunications to provide clinical care at a distance, patient and professional education, and health administration; and WHEREAS, the Monroe County Board of Commissioners recognizes that advanced technology should be a key part of the strategy to address clinician shortages in remote areas to meet the health care needs of our aging population, to minimize the vulnerability of health systems and their patients to medical errors, to provide cost-effective care to the uninsured, and to be prepared to meet medical threats of bio-terrorism and infectious diseases; NOW THEREFORE, BE IT RESOLVED BY THE BOARD OF COUNTY COMMISSIONERS OF MONROE COUNTY, FLORIDA that: The Monroe County Board of Commissioners hereby supports the development and promotion of telemedicine technology innovations in the State of Florida to bring better health care and health education to rural communities, and urges the Florida Legislature to approve funding to support pilot programs to demonstrate the value of telehealth networks to improve health services to Florida's underserved communities. 2. The Clerk is hereby directed to forward copies of this resolution to: Rep. Ron Saunders, District 120; Senator Lareenia Bullard, District 39; U.S. Congresswoman Ileana Ros-Lehtinen, District 18; Governor Charlie Crist; and also to Rep. Rene Garcia, Chair of the Florida House Committee on Health Innovation; and Senator Durell Peaden, Chair of the Florida Senate Standing Committee on Health and Human Services Appropriations. Passed and adopted by the Monroe County Board of Commissioners at a meeting held this 190' day of March, 2008_ Mayor McCoy Mayor Pro Tem Di Gennaro Commissioner Murphy Commissioner Neugent Commissioner Spehar (Seal) ATTEST: DANNY L. KOLHAGE, CLERK By: Deputy Clerk MONROE COUNTY BOARD OF COUNTY COMMISSIONERS By:T Mayor Charles "Sonny" McCoy MONROE COUNTY ATT NEY ROVED AS T VIV UZANN A. HUTTON cPyNT�r ATTOBNEr, Byron Hestwold 305 743 WW p.1 Mario De Gennaro, Mayor pro tem Monroe County, Florida Keys (305) 289-6000 phone (305) 299-6306 fax Dear Mr. De Gertuwo: RECEIVED JAN 15 2008 Jan- 14, 2008 One Quarter of America's population and one third of the elderly live in rural areas. The problem is that there are plenty of medical specialists in Florida, they just are not in the right places to help our rural population. Specialists tend to be located in large hospitals in our urban areas or at medical scl mis and their teaching hospitals. Modern electronic communications technology could help solve many of Florida's rural medical health care speciality problems. Rural hospitals and physicians could be helped with medical specialist shortages by being connected to Florida's public medical schools and their teaching hospital with telernedicine technology. This technology is now quite inexpensive and is very sophisticated. Florida's medical schools and their teaching hospitals have the necessary specialists on staff to help the state's rural health care providers. Our public medical schools and their teaching hospitals should be legislated and funded to meet more of Florida's rural health care needs through expanded telemedicine diagnostics and oansultiny. Teaching hospitals and their specialists would be paid for the services they provide to the rural patients and health care providers. More Health education courses for rural health care providers could also be provided by Florida's public medical schools by using new telecommunications technology and/or through the Internet. Florida's state medical schools and their teaching hospitals should be funded to be involved in both the nua'al consultation and the health care education functions. Medical school outreach programs should be encouraged by the state's health care budgeting and funding processes to benefit all of Florida's rural citizens and their health care providers. Programs like this are in effect in some areas and are not new. Passing legislation to establish a program for Florida's rural areas using the state's public medical schools and their teaching hospital would be new and would be a way to provide more medical specialty sevcces to all the people in Florida. if the Florida project is debugged and works well then it could be copied in other slates that have rural areas that have similar medical cane specialty shortages. Creative imitation is much easier than invention. Tax supported public medical schools and their teaching hospitals, if adequately fimded, could make their medical speciality expertise available to everyone in Florida and thereby improve the health care of many people for very little cost, The cost to establish a telemedicine network would be modest. The health rare benefits could be significant. Modem conunurncations technology, and public medical schools and their teaching hospitals should be used to meet the health care needs ofall the state's people. Please let me know if -Monroe County would support legislation to connect our rural hospitals to Florida's tax supported medical schools and their teaching hospitals to improve health care. Respectfully yours, VtO B46n O. Hestevold (305) 97-3-1993 cell, b h350-2mail.com P.O. Box 510506 Key Colony Beach, FL 33051-0506 - US -A -3-s Telemedicine Coming of Age Pagel of 3 telemedicine information exchange Published on the TIE (http://tie-telemed.org) online version of this page http:/ttie.telerned.org Telemedicine 101 Telemedicine Coming of Age By Nancy Brown, September 28. 1996 " Updated on January 13, 2005 Telemedicine has been defined as the use of telecommunications to provide medical information and services (Perednia and Allen 1995). It may be as simple as two health professionals discussing a case over the telephone, or as sophisticated as using satellite technology to broadcast a consultation between providers at facilities in two countries, using videoconferencing equipment or robotic technology. The first is used daily by most health professionals, and the latter is used by the military and some large medical centers. It is the practice of telemedicine somewhere in between those two that will be described in this article. Types of Technology Two different kinds of technology make up most of the telemedicine applications in use today. The first, called store and forward, is used for transferring digital images from one location to another. A digital image is taken using a digital camera, ('stored') and then sent ('forwarded') by computer to another location, This is typically used for non -emergent situations, when a diagnosis or consultation may be made in the next 24 - 48 hours and sent back. The image may be transferred within a building, between two buildings in the same city, or from one location to another anywhere in the world. Teleradiology, the sending of x-rays, CT scans, or MRIs (store -and -forward images) is the most common application of telemedicine in use today. There are hundreds of medical centers, clinics, and individual physicians who use some form of Teleradiology. Many radiologists are installing appropriate computer technology in their homes, so they can have images sent directly to them for diagnosis, instead of making an off -hours trip to a hospital or clinic. Telepathology is another common use of this technology. Images of pathology slides may be sent from one location to another for diagnostic consultation. Dermatology is also a natural for store and forward technology (although practitioners are increasingly using interactive technology for dermatological exams). Digital images may be taken of skin conditions, and sent to a dermatologist for diagnosis. The other widely used technology, two-way interactive television (IATV), is used when a'face-to-face' consultation is necessary. The patient and sometimes their provider, or more commonly a nurse practitioner or telemedicine coordinator (or any combination of the three), are at the originating site. The specialist is at the referral site, most often at an urban medical center. Videoconferencing equipment at both locations allow a'real-time' consultation to take place. The technology has decreased in price and complexity over the past five years, and many programs now use desktop videoconferencing systems. There are many configurations of an interactive consultation, but most typically it is from an urban -to -rural location. It means that the patient does not have to travel to an urban area to see a specialist, and in many cases, provides access to specialty care when none has been available previously. Almost all specialties of medicine have been found to be conducive to this kind of consultation, including psychiatry, internal medicine, rehabilitation, cardiology, pediatrics, obstetrics and gynecology and neurology. There are also many peripheral devices which can be attached to computers which can aid in an interactive examination. For instance, an otoscope allows a physician to 'see' inside a patient's ear; a stethoscope allows the consulting physician to hear the patient's heartbeat. Many health care professionals involved in telemedicine are becoming increasingly creative with available technology. For instance, it's not unusual to use store -and -forward, interactive, audio, and video still images in a variety of combinations and applications. Use of the Web to transfer clinical information and data is also becoming more prevalent. Wireless technology is being used for instance, in ambulances providing mobile telemedicine services. Programs and Applications There are many programs world-wide using a variety of technologies to provide healthcare. At the University of Kansas http://tie.telemed.org/articles/article.asp?path=tctemcd101&article=tmcoming nb tie96.x... 1/31/2008 Telemedicine Coming of Age Page 2 of 3 Telemedicine Program, telemedicine technology has been used for several years for oncology, mental health care to patients in rural jails, hospice care, and most recently, to augment school health services by allowing school nurses to consult with physicians. Several telemedicine programs are being initiated in correctional facilities, where the costs and danger of transporting prisoners to health facilities can be avoided. The University of Texas Medical Branch at Galveston Center for Teeehealth and_Distance Education was one of the original programs to begin providing services to inmates, and sees hundreds of patients per month. Home health care is another booming area of telemedicine, including Japan, the UK and the US. The Veterans Affairs Administration has initiated home telehealth as part of its telehealth program. Telemedicine does not have to be a high - cost proposition. Many projects are providing valuable services to those with no access to health care using low -end technology. The Memorial University of Newfoundland telemedicine project has been using low-cost store and forward technology to provide quality care to rural areas in under -developed countries for many years. The military and some university research centers are involved in developing robotics equipment for telesurgery applications. A surgeon in one location can remotely control a robotics arm for surgery in another location. The military has developed this technology particularly for battlefield use, and some U.S. academic medical centers and research organizations are also testing and using the technology. Advantages of Telemedicine Providing healthcare services via telemedicine offers many advantages. It can make specialty care more accessible to ///underserved rural and urban populations. Video consultations from a rural clinic to a specialist can alleviate prohibitive travel and associated costs for patients. Videoconferencing also opens up new possibilities for continuing education or training for isolated or rural health practitioners, who may not be able to leave a rural practice to take part in professional meetings or educational opportunities. While studies have yet to confirm this, it appears that the use of telemedicine can also cut costs of medical care for those in rural areas. Barriers to Telemedicine There are still several barriers to the practice of telemedicine. Many states will not allow out-of-state physicians to practice unless licensed in their state. The Centers for Medicare and Medicaid (CMS) still has several restrictions for Medicare telemedicine reimbursement. Many private insurers also will not reimburse, although some states, such as California and Kentucky, have legislated that they must reimburse the same as for face-to-face consultations. Other programs, such as Eastern Montana and Inland Health in Washington, have negotiated with payers for telemedicine reimbursement. Fear of malpractice suits is another consideration for physicians, as is acceptance of the technology and lack of 'hands-on' interaction with patients, although most patient satisfaction studies to date find patients on the whole satisfied with long distance care. (Gustke et al M) Many potential telemedicine projects have been hampered by the lack of appropriate telecommunications technology. Regular telephone lines do not supply adequate bandwidth for most telemedical applications. Many rural areas still do not have cable wiring or other kinds of high bandwidth telecommunications access required for more sophisticated uses, so those who could most benefit from telemedicine may not have access to it. Many current telemedicine projects side-step these and other problems by obtaining federal funds. However, in the past three to four years, federal funding has become less available for telemedicine. In 2005, the Technology Opportunity Program (TOP) will not receive funds for telemedicine/telehealth, and the Office for the Advancement of Telehea_ Ith (OAT) will not be able to fund any new programs. Some legislation and grant appropriations passed in response to 9/11 include the use of telehealth, but no direct funding has been made available. Some private corporations and telecommunications companies are stepping in to fill the void, however, pressure on the appropriate government and legislative agencies is needed before more funding will become available. Technology manufacturers and telecommunications companies are vying with each other to produce the low-cost equipment and bandwidth needed. Many states are creating networks which link education, government, business and healthcare. Distance education is commonplace and most educational institutions and many companies allay travel costs for meetings by using video. Telemedicine or Teleheaith? The term 'telehealth' was originally used to describe administrative or educational functions related to telemedicine. Now that physicians use email to communicate with patients, and drug prescriptions and other health services are being offered on the Web, 'telehealth' is generally used as an umbrella term to describe all the possible variations of healthcare services using telecommunications. The term 'telemedicine' more appropriately describes the direct provision of clinical http://tie.telemed.org/articles/article.asp?path=telemedl0l&article=tmcoming nb tie96.x... 1/31/2008 Telemedicine Coming of Age Page 3 of 3 care via telecommunications --diagnosing, treating or following up with a patient at a distance. However, stay tuned. The terminology used to describe healthcare services at a distance will likely change as fast as the technology used to perform it. Conclusion It's not too much of a stretch of the imagination to realize that telemedicine will soon be just another way to see a health professional, just as seeing friends and family while talking to them on the phone is becoming commonplace. Farther down the road, it has been theorized that we each could have a 'Personal Diagnosis System' as part of our home entertainment centers. This system would monitor our daily health status and automatically notify a health professional if we become ill. (Kurtz 1994) Fifteen or twenty years ago we had no idea we would rely heavily on faxes, answering machines and e-mail, tools which are now low -tech and taken for granted. In early 2005, telemedicine still has not reached its potential. However, information about telemedicine continually increases, there are many programs in operation since 1994, and telemedicine technology is usually included in hospital remodels or new hospitals. In the mid-90's Ronald C. Merrell, from Yale University School of Medicine said, "The innovations we will encounter as we step beyond feasibility are dazzling in their potential." (Merrell 1995) In 2005. the potential of telemedicine, telehealth and e-health is still left to our imaginations. References Gustke S S, Balch D C, West V L, Rogers L O. Patient satisfaction with telemedicine, Telemedicine Journal, Spring, 2000, 6(1): 5-13. (Link last checked on June 10, 2004). Kurtz G L. The future of telecommunications in rural health care. Healthcare Information Management, Summer, 1994, 8 (3): 5-9. (Link East checked on June 10, 2004). Merrell R C. Telemedicine in the 90's. Beyond the future. Journal of Medical Systems, 1995, 19(1): 15-8. (Link last checked on June 10, 2004), Perednia D A, Allen A. Telemedicine technology and clinical applications. JAMA, Feb 8, 1995, 273(6): 483-8. (Link last checked on June 10, 2004), Revisions May 3, 2003: checked links (N.B.) January 13, 2005: checked links; made edits (N.B.) About the author: Nancy Brown M.L.S., was the Research Librarian for the Telemedicine Research Center, in Portland, Oregon. She was also the Project Manager for Telemedicine Information Exchange (TIE). She has demonstrated the TIE at national and international meetings and has published several articles and a book chapter on the provision of Web - based information on telemedicine, as well as a compilation of telemedicine literature for the Medical Library Association. Pace last updated on Surde.d Jury 02 2005 Copyr�q-,t �_"' 995- 1008 Telemedicine Research Center P:,tlard, OR http://tie.telemed.org/articles/article.asp?path=telemedl0l&article=tmcoming nb tie96.x... 1/31/2008 DEPARTMENT OF HEALTH & HUMAN SERVICES I Mr. Byron O. Hestevold 540 Grandview Drive, Suite #5 Milford, Michigan 48381 Dear Mr. Hestevold: Health Resources and Services Administration Rockville, Maryland 20857 Thank you for your letter of September 4 to Deputy Secretary Troy in which you request funding from the Department of Health and Human Services (DHHS) to support a telehealth pilot project at the University of Michigan Medical System. We share your view that advanced technology is a key tool to bring, better health care and health education to rural areas such as those in the state of Michigan. We recognize that advanced technology should be part of our strategy to address clinician shortages in remote areas, to meet the health care needs of our aging population, to minimize the vulnerability of health systems and their patients to medical errors, to provide cost-effective care to the uninsured, and to be prepared to meets threats of bio-terrorism and infectious diseases. To this end, DHHS' Health Resources and Services Administration (HRSA) has been a i leader in supporting telehealth activities in rural and underserved areas. DHHS created the Office of Health information Technology (OHIT) within the Health Resources and Services Administration (HRSA) to promote health information technology advances and innovations. These include electronic health records, computerized decision support systems, home health, and other technologies that store, protect, retrieve and transfer clinical, administrative, and financial information electronically within health care settings. Further, OHIT oversees the Office for the Advancement of Telehealth (OAT), which has awarded over $250 million in grants to deploy electronic information and telecommunications technologies to provide clinical care at a distance, patient and professional education, and health administration. The Telehealth Network Grant Program (TNGP) supports telehealth networks that provide services in different settings (e.g., long- term care facilities, community health centers or clinics, physician offices, hospitals, schools, assisted living facilities) to demonstrate how telehealth networks can be used to: (a) expand access to, coordinate, and improve the quality of health care services; (b) improve and' expand the training of health care providers; and (c) expand and improve the quality of health information available to health care providers, patients, and their families. These grants have provided HRSA the valuable information to evaluate the use of telehealth technologies and programs; develop telehealth policy initiatives to improve access to quality health services; and assess technology investment strategies. In addition, these grants help foster partnerships across HRSA and with other Federal agencies, states and private sector groups and provide technical assistance and promote knowledge exchange about "best telehealth practices." Page 2- Mr. Byron O. Hestevold HRSA recently completed its grant competitions this year, therefore funds are not available at this time for the project contemplated in your letter. We encourage you to visit our website httn://www.hrsa.aov/healthit/, which contains an overview of the Office of Health Information Technology. We also encourage you to visit the OAT website at httl2://telehealth.hrsa.gov/, which contains a Grantee Directory listing of telehealth projects that have been funded in Michigan and elsewhere. The website also contains a Telehealth Funding Guide and other useful links to other organizations involved in telehealth. You may also be interested in learning more about the Resource Center funded in the state of Michigan at Marquette University, which was competitively funded for a three-year period in 2006 under the Telehealth Resource Center Grant Program (TRCGP). This program supports the establishment and development of centers of excellence that assist health care organizations, health care networks, and health care providers in the implementation of cost- effective telehealth programs to serve medically underserved communities. Resource Centers comprise mature, successful telehealth programs and consortia of programs to assist start-up and nascent telehealth programs in their development and provide a resource to existing programs in the implementation of more effective and sustainable telehealth services. The Resource Centers provide technical assistance that addresses a wide range of challenges to implementing programs from day-to-day operational issues to creating financially sustainable programs. For more information on the Resource Center in Michigan, you may contact Sally Davis at (906) 225-3120, or you may visit their website htt-o://www.mizh.org/telehealth/. We hope this information is helpful. If you have further questions or require additional information, please feel free to contact Dena Puskin, Director of the Office for the Advancement of Telehealth at (301) 443-3682. Sincerel , Cheryl Austein Casnoff, MPH Associate Administrator Office of Health Information Technology Florida House of Representatives - Committee on Health Innovation Page 1 of 1 ----­1 Committee on Health Innovation Y Location: 214 House Office Building * 402 South Monroe Street * Tallahassee, FL 32399-1300 Contact: (850) 487-2242 Next Meeting: No Scheduled Meeting Representatives: Garcia, Rene (R) Chair Patronis, Jimmy (R) Vice Chair POrth, Ari Abraham_ (D) Democratic Ranking Member Frishe, James C. (R) Gonzalez, Eduardo (R) Homan, Ed (R) Sacha+ Marla Lorts JD) Sands, Franklin (D) Weatherford, Will W. 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