On October 7, 1996, Secretary of Health and Human Services Donna E. Shalala announced that the National Library of Medicine (NLM), a part of the National Institutes of Health, was funding 19 projects with a total budget of $42 million to develop health care applications of the national information infrastructure. The multiyear projects, located in 13 states and the District of Columbia, will serve as models for evaluating the impact of telemedicine¹ applications on cost, quality, and access to health care; assessing various approaches to ensuring the confidentiality of health data transmitted via electronic networks; and testing emerging health data standards. The Agency for Health Care Policy and Research is co-funding one of the 19 projects. The following project summaries are derived from a list of project descriptions prepared by NLM and are available on-line at nlm.nih.gov/research/initprojsum.html.

1. Provide health care to underserved center-city elderly and offshore islanders in California. The University of Southern California's Medical faculty will treat multiple underserved communities ranging from North Hollywood's center-city elderly and minorities to the rela-

1. tively isolated offshore island of Catalina via state-of-the-art telemedicine systems. Patients will be cared for in their own locale by means of PacBell network transmittal of USC Emergency medicine support instead of having to travel to distant specialists (e.g., by helicopter or boat from Catalina).
   
   

   Contact: F.W. George III, M.D.

   University of Southern California

   Advanced Biotechnical Consortium

   1537 Norfolk Street, DEI-5103

   Los Angeles, CA 90033

   (213) 342-3671

2. Support rural primary care physicians consulting with remote specialists in West Virginia. A consortium of nine institutions led by the Concurrent Engineering Research Center of the West Virginia University will demonstrate the viability of secure clinical telemedicine on public telecommunication networks and show that its adoption as an integral part of an overall health care plan can result in cost savings and improved access to quality health care for rural populations. Rural primary care physicians, physicians' assistants, and other authorized users will have secure access to electronic medical records and patient monitor data, and be able to confer with collaborating health care providers at a distance in the treatment of patients.
   
   

   Contact: Ramana Reddy, Ph.D.

   Concurrent Engineering Research Center

   West Virginia University

   886 Chestnut Ridge Road

   Morgantown, WV 26506

   (304) 293-7226 (304) 293-7541(fax)

3. Improve care to high-risk newborns and their families in Massachusetts. Beth Israel Deaconess Medical Center will use telemedicine to provide educational and emotional support to families of high-risk newborns both during their hospitalization and following discharge. This innovative use of technology should increase parents understanding of their baby's continuing medical needs and provide a clear cost savings. Prior to their baby's discharge from the hospital, parents will be able to observe the baby's care via a television monitor in their home. Following discharge, patients in their homes will continue to be connected via television to Beth Israel Hospital. The trial will examine the potential of

3. telemedicine to decrease the cost of care for very-low-birth-weight infants by increasing the efficiency of care.
   
   

   Contact: Charles Safran, M.D.

   Principal Investigator

   Beth Israel Deaconess Medical Center

   350 Longwood Avenue

   Boston, MA 02115

   (617) 732-5925

4. Test real-time transmission of vital sign data from patients in ambulances to a hospital trauma center in Maryland. BDM Federal Inc. and the University of Maryland at Baltimore will develop an advanced mobile telemedicine testbed that will investigate the feasibility and practicality of transmitting real-time vital sign data and video images of patients from inside the ambulance to the hospital's trauma center and clinical information system via cellular communications and local area network technology. The purpose of the mobile testbed is to improve the quality and timeliness of care provided during the "golden hour" and to provide better information to the emergency room (ER) staff prior to the arrival of patients in the ER. If proven feasible, this mobile telemedicine application could be used in trauma centers throughout the United States.
   
   

   Contact: David Gagliano

   BDM Federal Inc.

   1501 BDM Way

   McLean, VA 22102

   (703) 848-6134

5. Improve disease prevention and manage chronic illnesses in home settings in New York. Columbia University will use technology to provide information to patients to improve disease prevention activities and effectively manage chronic illnesses in the home setting. Patients will receive alerts and reminders when standards of care (immunization, diabetes management, asthma control, etc.) are not being achieved. Patients will enter data (blood pressures, glucose levels, pulmonary function test results, etc.) into an electronic medical record using applications that run on home-based personal computers connected to the national information infrastructure (NII). These patients will also be able to communicate with health care providers, review their medical records, and receive desired information that will address their specific health care concerns. The project will demonstrate techniques to safeguard the confidentiality of personal health care records that are stored and transmitted electroni-

5. cally, and will evaluate the impact of patient use of information via the NII.
   
   

   Contact: Soumitra Sengupta, Ph.D.

   Assistant Professor

   Department of Medical Informatics

   Columbia University

   161 Fort Washington Avenue

   New York, NY 10032

   (212) 305-7035

6. Prevent adverse drug interactions among the elderly in Missouri. Adverse drug interactions are often a problem, particularly among the elderly and others who take multiple medications. Sometimes the wrong dosage makes a medication more harmful than beneficial. But in St. Louis, and neighboring towns in Illinois, six hospitals are learning to prevent these problems, using the extensive telemedicine network that already links them. By year's end, they will be able to ensure that patients are taking the correct dosage of their medications, and to prevent or quickly respond to harmful drug events. Using pharmacy orders and patient data such as age, sex and weight, Dose Checker examines the prescriptions a patient is taking and issues dosage warnings when warranted. The other system, the Adverse Drug Event (ADE) Monitor, pulls together patient drug orders and laboratory test results, alerting hospital pharmacists when it detects signs of adverse reactions. Doctors and other health professionals will be notified immediately when a patient is at risk. This project was co-funded by the Agency for Health Care Policy and Research.
   
   

   Contact: Michael Kahn, M.D.

   Barnes-Jewish Hospital

   216 South Kings Highway

   St. Louis, MO 63110

   (314) 454-8651

7. Provide vital health information to health professionals in rural and urban settings across the Northwest. The University of Washington Academic Medical Center regional telemedicine network will connect health professionals and patients from big cities, small towns, and vast expanses of sparsely populated areas in Washington, Wyoming, Alaska, Montana, and Idaho to provide timely access to vital health information. The University of Washington links clinical and public health partners at selected sites in this five-state area via a regional telemedicine network

7. that includes a World Wide Web interface to electronic medical records; secure clinical e-mail for clinician-to-clinician and clinician-to-patient interactions; electronic delivery and management of x-rays and other clinical images; and access to medical library resources, such as MEDLINE and full-text journals. This innovative network will allow clinicians to consult with one another, health professionals and their patients to confer, and all to access medical information, despite the long distances that separate them.
   
   

   Contact: Sherrilynne Fuller, Ph.D.

   University of Washington

   A-327 Health Sciences Center

   Box 356340

   Seattle, WA 98195-6340

   (206) 616-5808

8. Provide patients with access to their own medical records while preserving confidentiality of that information in California. In a cooperative effort with the Science Applications International Corporation (SAIC), the University of California, San Diego has launched PCASSO, a project designed to enable patients, health care providers, and medical researchers to access clinical information over the Internet without any breaches of confidentiality. PCASSO will use everyday World Wide Web technology to support information search and retrieval, and state-of-theart security technology to ensure patient privacy and the integrity of patient information. The project represents a new thrust within the health care industry: to provide patients more control over and access to their own medical records while preserving the confidentiality of that information.
   
   

   Contact: Dixie Baker, M.D.

   Science Applications International Corporation

   10260 Campus Point Drive

   San Diego, CA 92121

   (310) 615-0305

9. Transmit and manage brain and breast images and associated medical data in four California medical centers. This project, coordinated by the Department of Radiology at the University of California at San Francisco, is focused in scope but may prove to have far-reaching consequences for health care delivery. It links four San Francisco-area medical centers electronically, for the transmission and management of neuroradiology and mammography images. The hope is that a high-

9. performance tele-imaging information infrastructure will enhance health care in the Bay Area by improving telediagnosis, teleconsultation, telemanagement, teleresearch, and tele-education. Then, perhaps, this model can be extended to include other types of medical images, and other parts of the country.
   
   

   Contact: H.K. Huang, D.Sc.

   University of California, San Francisco

   Department of Radiology

   School of Medicine

   530 Parnassus Avenue, RM CL-158

   San Francisco, CA 94143-0628

   (415) 476-6044

10. Measure the effectiveness of video consultations for patients with special needs, including children with disabilities or heart conditions and persons with mental illness in Iowa. The University of Iowa's National Laboratory for the Study of Rural Telemedicine was created in 1994. Now, with support from NLM, that group will expand its efforts in two directions: clinical consultations and the use of specialized databases in health care delivery. A series of projects will measure the effectiveness of video consultations for patients with special needs, including children with disabilities or heart conditions and persons with mental illness. Another project will give community hospital emergency rooms access to information and expertise by providing special database software and allowing teleconferencing with physicians at the University of Iowa Health Center. NLM funding will also support an innovative project to deliver health information into the homes of people with diabetes. They will receive an easy-to-use device that attaches to their TV and provides access to on-line health information. Researchers hope that this project will help diabetes patients manage their disease more effectively.
    
    

    Contact: Michael Kienzle, M.D.

    University of Iowa

    National Laboratory for the Study of Rural Telemedicine

    Telemedicine Resource Center

    1-204 MEB

    Iowa City, IA 52242

    (319) 353-5621

11. Analyze the benefits of rural telemedicine services by linking health professionals in three small Missouri communities. The University of Missouri-Columbia School of Medicine will implement and then

11. analyze the benefits of rural telemedicine services, working with three small rural Missouri communities. In addition to creating links among the health professionals in each community, the project will connect rural providers to colleagues in other participating towns and to the university's Health Sciences Center, with its four hospitals, extensive medical library, hundreds of specialists, and other resources. Studies will involve tracking utilization of this new network, assessing rural providers' needs, and noting any changes in health care utilization patterns and retention of health care personnel in rural communities after the network is in place. Costs of and savings from this venture will also be carefully reviewed.
    
    

    Contact: Joyce A. Mitchell, Ph.D.

    University of Missouri-Columbia

    School of Medicine

    Medical Informatics Group

    605 Lewis Hall

    Columbia, MO 65211

    (573) 884-7717

12. Expand robust health care network that provides rapid access to patient record data in Indiana. With new funding from the NLM, Indiana University School of Medicine will broaden the scope of its existing Indianapolis Network for Health Care of hospital emergency rooms, clinics, HMOs, homeless care sites, and pharmacies, so that more people can enjoy its benefits. Already this technically robust network provides instant access to patient records in emergency rooms and efficient access to medical library resources at numerous care sites, and permits collection of prescription information from a large chain of community pharmacies, to improve drug prescribing patterns in a range of health care facilities. New network linkages will include the Indiana State Public Health Department and a number of large clinical laboratories. Among other benefits, these additions to the network will provide clinicians on the network with better immunization data from health departments and will enable electronic reporting of communicable diseases from high-volume Marion County clinical laboratories to the relevant public health departments.
    
    

    Contact: Clement J. McDonald, M.D.

    Indiana University, Regenstrief Institute

    Department of Medicine

    1001 W 10^th Street, Fifth Floor

    Indianapolis, IN 46202-2859

    (317) 630-7400

13. Provide health care teams with computer systems to assist in outpatient care in Illinois. The goal of Northwestern Memorial Hospital's Net Reach project is to provide health care teams with computer systems to assist in outpatient care, and to evaluate the impact of their use. The project observed practicing clinicians at seven diverse outpatient clinics (primary care, specialty care, faculty group practice, independent group practice, and urban care clinics) to understand and specify the information needs of clinicians. Based on the requirements derived from the information needs study, they implemented information tools, including a computer-based patient record at one site, to address the clinicians' needs. During the NLM-funded extension, the project will evaluate the impact of information technology on clinical and operational performance of physicians and on patient and provider satisfaction.
    
    

    Contact: Paul Tang, M.D.

    Northwestern Memorial Hospital

    Information Services

    259 East Erie, Suite 600

    Chicago, IL 60611

    (312) 908-4034

14. Increase the efficiency and improve the quality of emergency room and primary care in Indiana. The Indiana University School of Medicine will create the Indianapolis Network for Patient Care, a shared clinical data repository that will store encounter records, hospital abstracts, clinical laboratory data, prescription data, and other data for use by emergency room departments and primary care providers in the Indianapolis area. This repository will encompass 90 percent of Indianapolis's hospital emergency room care data and data from two managedcare systems, as well as a major share of the laboratory and hospital encounter data of the city. The purpose of this effort will be to increase the efficiency and improve the quality of emergency room care and primary care by providing the responsible physicians with laboratory and other data important to care. The completion of this project should result in a workable model for access and confidentiality for large-scale shared community clinical data.
    
    

    Contact: Clement J. McDonald, M.D.

    Indiana University, Regenstrief Institute

    Department of Medicine

    1001 W 10^th Street, Fifth Floor

    Indianapolis, IN 46202-2859

    (317) 630-7400

15. Provide telemedicine services to renal dialysis patients and information services for caregivers in the District of Columbia. Georgetown University Medical Center already has an extensive network consisting of radiological imaging nodes and hospital information systems that provide support to the nephrologists at the medical center and at home. The network links Georgetown University Medical Center, remote outpatient kidney dialysis clinics, and nephrologists' homes. The primary functions of the network are to provide telemedicine services to renal dialysis patients, to create, manage, transfer, and use electronic health data and to provide decision support and information services for caregivers. This project will test the general hypothesis that by facilitating electronic interactive communication among physicians and patients, quality of patient care will be improved and lower costs to patients, physicians, and the health care system will be incurred.
    
    

    Contact: Seong Ki Mun, Ph.D.

    Georgetown University Medical Center

    37th and O Streets, N.W.

    Washington, DC 20057

    (202) 784-3483

16. Establish a network for prevention and health care in Massachusetts. Increased access to information resources and technology allows consumers to take greater responsibility for health and wellness, as well as for their own health care. Boston College and the Partners HealthCare System will examine the impact of public education and access to information on matters of lifestyle and health; patient access to information about specific health problems; support for health care providers for facilitating optimal care practices; and clinical services provided by the health care system.
    
    

    Contact: Robert A. Greenes, M.D.

    Brigham and Women's Hospital

    75 Francis Street

    Boston, MA 02115

    (617) 732-6281

17. Evaluate the impact of telemedicine technologies and applications on the health care system in rural Alaska. As federal health care contributions to health care systems decrease, and as the population of Alaska changes, telemedicine is seen as a strategy for cost containment and for increasing the quality of health care delivery that, in Alaska, has traditionally relied on the transportation of patients over long distances.

17. The objective of this project is to replicate existing and developed Alaska telemedicine testbeds by modifying, interfacing, and expanding successfully deployed telemedicine technologies and to evaluate the impact of these technologies on the health care system in rural Alaska for cost, quality of care, and access to care by rural Native Alaskans where and when it is needed.
    
    

    Contact: Frederick W. Pearce, Ph.D.

    University of Alaska Anchorage

    Applied Science Laboratory

    3211 Providence Drive

    Anchorage, AK 99508

    (907) 786-4183

18. Use teledermatology to improve the ability of primary care physicians to recognize and treat skin cancers and other skin conditions in Oregon. This extension of an NLM contract at the Oregon Health Sciences University in Portland, Oregon, will expand the range of technologies used to provide remote dermatologic diagnosis and will collect and analyze data on teledermatology's impact on the quality and cost of health care.
    
    

    Contact: Douglas A. Perednia, M.D.

    Oregon Health Sciences University

    3181 SW Sam Jackson Park Road

    Portland, OR 97201

    (503) 494-6846

19. Improve the quality and efficiency of patient care by providing physicians with rapid access to important clinical information in a single, easy-to-use workstation environment in Pennsylvania. An extension of an NLM contact at the University of Pittsburgh will evaluate the clinical utility of a multimedia clinical information system at the University of Pittsburgh's Cancer Institute. Currently, the system can acquire, compress, store, retrieve, display, and manipulate many kinds of clinical images, including radiographs, CT scans, nuclear medicine studies, gastrointestinal endoscopy images, EKGs, and microscopic pathology. These images are linked, in real-time, with a wide range of clinical reports stored in the University of Pittsburgh Medical Center's electronic medical record system. The project will study the effect of integrated access to clinical images and textual patient data on the length of time required to diagnose cancer and on the management of cancer treatment.

• Contact: Henry J. Lowe, M.D.
  
  

  Section on Medical Informatics

  University of Pittsburgh

  B50A Lothrop Hall

  Pittsburgh, PA 15261

  (412) 648-3190