Final Recommendation
Project 3 Team 1
Dorothy Skowrunski
Sarah Stottsberry
Rural Health Care Statistics
Rural Americans face a unique combination
of factors that create disparities in health
care not found in urban areas. Economic
factors, cultural and social differences,
educational
shortcomings,
lack
of
recognition by legislators and the sheer
isolation of living in remote rural areas all
conspire to impede rural Americans in their
struggle to lead a normal, healthy life. i
Current Health Care in Morgan County
Morgan County is a federally designated
Health Professional Shortage Area (HPSA).
This classification is determined by the
collection and analysis of demographic and
provider data to determine geographic
areas that are underserved by health
professionals.
This
designation
is
determined by the state and allows these
communities to apply for recruitment and
retention assistance through state and
federal programs.ii
Morgan County currently has:


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
1 - Full service pharmacy that
provides durable medical
equipment covered by insurances
and Medicare/Medicaid.
Registered pharmacists are on staff
1 - Morgan County Health
Department offers a variety of health related services including health screening,
immunizations, and medical referrals
2 – Physicians
2 - Licensed Nursing Homes
1 – Licensed Residential Care Facility
1
Morgan County also has many health care service providers within their surrounding area. The
following chart shows the distance in miles and minutes of locations providing services to Morgan
County. The closest is 36 minutes /26 miles away and the farthest is 144 minutes / 129 miles away.
MedFlight helicopter service is also available in Morgan County.
http://apps.nlm.nih.gov/medlineplus/local/ohiosoutheast/localtopic_details.cfm?areaid=14&service_id=209&location_type=County&location_id=907&invokedby=services#local
Telehealth/Telemedicine: A Possible Solution to this Problem
Health care in the future must be effective and efficient if all of the population is to receive adequate
services from the limited human resources. Telehealth can help improve the efficiency of healthcare
workers and can help reduce the exacerbation of diseases that increases the time required by patients.iii
The term 'Telehealth' was originally used to describe administrative or educational functions related to
telemedicine. Telehealth encompasses the curative aspect along with a wide array of services including
administrative and educational functions related to Telemedicine. Additionally, Telehealth does not
focus on one particular technology; rather it stresses the importance of relying on a variety of
technological solutions in order to provide value to all participants.iv 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 care via telecommunications--diagnosing, treating or following up with a
patient at a distance. Technologies such as telephones, email, computers, interactive video, digital
imaging equipment, and monitoring devices make it possible for a remote clinician to evaluate and treat
a patient without having to physically be with them. However, the terminology used to describe
healthcare services at a distance will likely change as fast as the technology used to perform it.
2
Service
Example(s)
Telemedicine
Phone Call; Robotic Surgery; Remote Psychiatric Care; Remote In-home
chronic disease monitoring
Education/Training
Continuing Education for Healthcare Providers; Patient Education; Family
Education
Administration
Management of Electronic Medical Record
Types of Telehealth Service Delivery
While Telehealth aims at encompassing a myriad of services, the sophistication of these services varies
significantly. In its simplest form, a phone conversation between a physician and patient could be
considered a Telehealth service. On the other hand, it could be as sophisticated as a physician
performing an examination of a patient using high-definition video conferencing. Generally speaking,
two different kinds of delivery models make up most of the telemedicine applications in use today. The
first called store and forward is used for transferring digital images and data from one location to
another. The second is two-way interactive communication which is used when a “face-to-face”
consultation is necessary. Many health care professionals involved in telemedicine are becoming
increasingly creative with available technology. It is 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 in use for
instance, in ambulances providing mobile telemedicine services today. However, 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. Today, many organizations are utilizing low-cost store
and forward technology to provide quality care to rural areas such as Morgan County.
Channel
Description
Applications
Store and Forward
Telehealth
Digital images, video and audio data
captured by way of the client computer
and stored on the device. In time, this data
is forwarded to a remote clinic via
telecommunication technology.
Remote Patient Monitoring/Home
Health Care, Telepathology,
Dermatology, Radiology (X-rays, CT
scans & MRIs), Computer and Web
Based Training.
Real-Time Telehealth
Use of two-way audio and video
technology in order to provide real-time
services. Video conferencing technology
historically is the preferred method of
telecommunication in this type of service.
Remote Patient Monitoring/Home
Health Care, Psychiatry, Oncology,
Internal Medicine, Rehabilitation,
Cardiology, Pediatrics, Obstetrics,
Surgery, Gynecology and Neurology ,
Dermatology, Radiology, Real-time
Education and Training.
3
Patient Needs
Morgan County does not have local access to primary care services, secondary care and specialist
physicians. Travel into a city for medical care takes time and may be impossible during inclement
weather. The terrain of Morgan County increases the travel time. The roads are hilly, curvy and in
many areas, poorly maintained. When a patient travels a long distance for care, they must incur the
expense of travel and often they must be away from their employment, which results in lost wages
and/or decreased productivity. Many times patients that do not have a medical facility in their
community do not travel for needed care. As a result, their condition can worsen causing hospitalization
and increased cost and burden on the family. Morgan County patients with chronic diseases such as
diabetes and congestive heart disease are in need of almost continuous care. Medical services and
education/training need to be available in Morgan County and possibly in the patient’s home in order to
keep their disease under control and maintain their health. As the baby boomer population continues
to age, there will become a greater need for a strong Telehealth program in rural areas. Much of
Morgan County’s population (40%) is in the baby boomer category. Many older adults have health
issues that go untreated and others have a need for preventive services. The percentage of people
without health insurance also continues to increase. A Telehealth solution would help ease the total
cost of health care.
There is also an economic impact on Morgan County when a patient travels outside the community.
Dollars spent on medical care and other trip-associated expenses stay in the city that provides the care
and not in Morgan County or near the patient’s home.
Health Care Provider Needs
Many heath care providers do not have the time to obtain continuing education/training, especially if
they live in rural or remote communities. Participation in distance learning can reduce clinician isolation
and increase satisfaction. This is an important strategy for the retention of providers and other
clinicians in rural health care organizations. Morgan
County’s clinicians who participate in Telehealth
networks are able to increase skills and confidence in
treating conditions traditionally outside the scope of
primary care. This would also benefit Morgan County
residents and their healthcare organizations. As we
consider Telehealth applications, we will need to
consider the education/training needs associated with
the application. Healthcare providers are the key
personnel in designing, implementing, training and
executing any Telehealth project. While Morgan County may not attract healthcare providers to live in
the area, distance learning presents opportunities for Telehealth through the following applications:
 Online University Instruction: An Internet connection can provide the resources needed to
participate in online degrees and continuing education.
4

Video Conferencing: Offers a visual and audio context for distance learning that is comparable to
conventional classroom instruction.v
Health Care Organization/Administration Needs
Having an advisory group for patients and providers is essential throughout the process of the
development of a Telehealth program. Morgan County will need to create or become part of an
organization that is financially viable in order to provide services to patients.
Morgan County Telehealth Care Survey Results
We administered a survey to gather Telehealth opinions from a diverse group of individuals living in a
rural community similar to Morgan County. Participants were asked a series of closed ended questions
as well as given the opportunity to make comments. The primary purpose of the study was to obtain
feedback from individuals regarding healthcare issues that affected their lives.
Some interesting results of the survey are:
 No one knew what Telehealth was before participating in the study. They needed a brief
explanation before completing the survey.
 The belief was it was neither a problem driving a distance for healthcare or healthcare
education/training nor would the cost of gas be a problem.
 The vast majority of participants would support and take advantage of a Telehealth
/telemedicine initiative, are comfortable with the idea and believe it would provide a quality
experience. (See Appendix C - Table 3 for a sample survey and the complete survey result.)
Applications
While there are many Telehealth applications available today, our survey results indicate that while
Morgan County is rural area, the need to travel a long distance for critical care was not a challenge.
Most individuals feel that when faced with a serious condition, especially related to the area of pediatric
care, expenses related to travel and specialty care was not a concern. However, situations that warrant
constant monitoring and care were ones that they felt most applicable to Telehealth. Therefore, we
have focused our analysis on Chronic Disease Maintenance, Mental Health, Prenatal Care, and Pre/Post
Surgery Consultation.
Chronic Disease Maintenance
According to the Columbus Dispatch, chronic disease maintenance is costing Ohio nearly $57 billion a
year.vi Morgan County, with over 40% of its population over the age of 45, is not alone in its need to
minimize the costs of chronic disease maintenance. However, as we have already shown, it presents
significant challenges given its remote location to specialized services and the population’s inability to
access care. Telehealth applications could be a way for Morgan County to gain better control in this
area.
5
Since access to local clinics is sparse, we feel an in-home disease maintenance application would be
valuable to the population of Morgan County. Chronic Disease maintenance is highly adaptable to home
Telehealth practices since chronic disease can present challenges including the need for repeated
hospitalizations and frequent monitoring of the following statistics:
 Vital Statistics
 Diet
 Specialized Tests
 Medication Changes
There are many home Telehealth devices that can monitor statistics related to the following conditions.
These devices typically require only a normal phone line connection, and offer a wealth of monitors
including blood glucose, weight, blood pressure, fluid status, pulse oximeters, peak flow meters, and
spirometers.
 Congestive Heart Failure(CHF)
 Chronic Obstructive Pulmonary Disease(COPD)
 Asthma
 Diabetes
 Hypertension
 Obesity
These devices not only offer the appropriate tests and tools needed to monitor the conditions, they also
offer easy to use interfaces and friendly reminders to the patient. In no time at all, it makes disease
maintenance feel like a normal part of everyday life, and ultimately is preventing further damage and
the need for hospitalizations in the future.
Mental Health
The National Institute of Mental Health estimates that 1 out of every 4 adults, 18 years of age and older,
will be diagnosed with a mental disorder during a given year.vii This amounts to a total of 57 million
people a year. This is a staggering statistic and one that rural areas like Morgan County find very
challenging. Given that population density is low, the actual numbers affected by mental disease will be
slim in comparison to suburban or metropolitan areas. Therefore, providers rarely look at places like
Morgan County as desirable service areas, and ultimately the population is left to travel to find these
services. Often times, the patient attempts to ignore the problem and does not seek treatment.
Telehealth Options for Mental Health
In reviewing examples of Telehealth technologies that we could employ for use in treating mental
conditions, we paid close attention to the need for privacy in rural areas. Obtaining mental health
services in a metropolitan area is very different from that of a rural area where it is likely that the
inhabitants are acquaintances. Not only will home Telehealth help to provide expert resources for
mental health conditions, but it clearly can offer a level of privacy that is not available with traditional
psychological and psychiatric care given that the patient does not have to leave his/her home.
6
TelePsychology
Examples of applications that could be beneficial to rural areas:
Application
Purpose
Internet Access to Psychological Information
Self awareness and need to request other services
Single Session Psychotically Advice via Email
Used for minor situations or could be something
that consumer is “trying out”
Ongoing Personal Counseling and Therapy
Used for significant challenges that requires time
to resolve.
Real-Time Counseling
Through use of Chat, Web Telephony, or
Videoconference offers a more personal approach.
Applied & Preventive Psychology 8:231-245 (1999). Cambridge University Press. Printed in the USA 1999 AAAPP 0962-1849/99
TelePsychiatry
This is a term used to describe the psychiatric, diagnosis, consultation, and treatment of mental
disorders via real-time, interactive videoconference.viii
While psychological disorders require
counseling, Telepsychiatry incorporates the use of telemedicine since psychiatric disorders are often
times treated with medication. Similar to Telephychology, the following applications are likely to be
beneficial to the population of a rural area.
Application
Purpose
Internet Access to Psychiatric Information
Self awareness of condition, and knowledge of
drugs used to treat conditions
Initial and On-Going Consultation through
Videoconferencing.
In-home consultation by way of webcam, or other
video conferencing hardware.
Remote Monitoring of Medication Levels
Remote monitoring device could be used in home.
Prenatal Care
High Risk pregnancies present significant challenges to women who live in rural areas. While the initial
diagnosis is made by a certified OB/GYN doctor, the ongoing maintenance of the condition makes it a
likely candidate for a Telehealth application in Morgan County. With 34% of its population in
childbearing age range of 18 years – 44 Years, there are many opportunities for Telehealth. High Risk
pregnancies occur for many reasons including the following.
7
OB History Risk Factors
Medical History Risk Factor
Physical Factors

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


Previous Still Birth
Previous Premature
Previous Caesarian Section
Abnormal PAP Test
Chronic Hypertension
Thyroid Disease
Maternal Age over 35 Years
Uterine Malformations
http://www.obfocus.com/questions/qanda13.htm
While we suggest ongoing in-person monitoring of the high-risk pregnancy, for persons that would likely
forgo the monitoring due to the inability to access or pay for care, remote in-home Telehealth
monitoring of high-risk pregnancies would provide great benefits. Simple monitoring of the fetal heart
rate can be extremely beneficial at preventing stillbirth and pre-term delivery.ix There are several
applications that are available on the market that provide a monitoring belt that can be used to check
the fetal heart rate at various times during the day. The results are sent electronically to the attending
physician. Some believe in-home monitoring actually offers better prevention than in-clinic
consultations simply because the belt can be used during late times of the day, which usually would not
be possible with a normal office visit.
Pre/Post Surgery Consultation
With 2 hospitals within a 50 mile radius of Morgan County, it is unlikely that there will be a need for
Telesurgery applications. However, pre-operative treatment and surgery planning, and postoperative
care offer many opportunities for the use of Telehealth in Morgan County. Researches indicate that
improper pre-operative care is a leading cause of death due to surgery. x
Preoperative Applications



TeleRadiology: Electronic Transmission of radiological images like x-rays, CT’s, and MRI’s that
help to identify surgical needs.xi
Access to Instructions via Email or Internet
Friendly Reminders via Email or Telephone
Post Operative Applications
 Post Operative Follow-up: Consultations via Email or Videoconference
 TeleRehabilitation: While Physical and Respiratory Therapy may begin in the hospital, continual
rehabilitation may be possible through remote access to information including text and video
instructions, along with video conferencing allowing for the provider to verify results and/or the
ability to monitor the patient from a distance.

In-clinic monitoring: in cooperation with Morgan Counties long-term care facilities. Possible
applications include remote conferencing, or email communication regarding rehabilitation
8
Technology
As shown in Appendix F, there are many technologies that are used in the delivery of Telehealth
services. These include the software, hardware, and peripheral devices that are used for examining,
monitoring, and communicating with a patient from a distance. Through our analysis of these
technologies, it became clear that there is a hierarchy in the infrastructure that is required to transmit
data at varying stages of Telehealth as depicted in the following table.xii
Advanced
Telehealth
Modern
Telehealth
Beginning
Telehealth
Additionally, there are technologies that are used to provide the telecommunications link needed to
support these technologies. We have performed an analysis of these telecommunications technologies,
shown in Appendix D. While there are many known options, Morgan County currently has a limited
availability of these technologies as shown in Appendix E.
The Pyramid of Value
Through our needs analysis and technology analysis, we discovered an important relationship between
the two. While there are many applications of Telehealth that could be useful for Morgan County, each
can logically be mapped to a particular phase of Telehealth. As depicted below, simple applications like
Telenursing and Teleobstetrics can be explored with technologies defined in the beginning phase, while
more advanced applications like telepsychiatry and Teleradiology would be categorized as a modern to
advanced Telehealth application. Additionally, in the future, there may be even more sophisticated
applications that could provide value to Morgan County.
9
Figure 1
Phase 4: Future
Telecommunication: County-Wide
Mobile Broadband
Applications: In-home, Mobile Personal
Diagnosis Application
Phase 3: Advanced
Telecommunication: County-Wide Broadband
Applications: Teleradiology, In-home applications of
TelePsychiatry, TeleRehabilitation, Telesurgery
Phase 2: Modern
Telecommunication: Moderate Broadband Access
Applications: TeleRehabilitation, TelePsychiatry, Teleradiology
Phase 1: Beginning
Telecommunication: POTS
Applications: Telenursing; In-Home Teleobstetrics Monitoring;
As shown in Appendix A, there is currently a limited availability of broadband access throughout the
county. However, in order to provide a sustainable Telehealth initiative in Morgan County, it will be
necessary to establish a telecommunications infrastructure that will support Telehealth applications
starting now and continuing into the future. While there are many applications that could be initiated
through access to a plain old telephone system (POTS), Morgan County will undoubtedly need to have a
broadband infrastructure to support more sophisticated applications in future. This infrastructure not
only can meet the bandwidth requirements of simple in-home monitoring devices, but could also
support data intensive applications in the future that require such technologies as video conferencing.
It is this natural order of progression that is at the heart of our recommendation to Morgan County.
Seven Steps of Telehealth Planning for Program Success
Upon being tasked with providing a recommendation to Morgan County for a county-wide Telehealth
network, we started by reviewing the history of Telehealth. While the act of using smoke signals to
warn of disease, or using two-way radios to communicate with the Royal Flying Doctor Service in remote
areas of Australia are very primitive forms of Telehealth dating back to the 1900’sxiii, the past 40 years
has been a time of experimentation and progress. This was first seen by Psychiatrists in the 1950’s,
Dermatologists in the 1960’s, and benefits to the study of radiology began during the 1990’sxiv.
Although it has been around for over a century, areas like Morgan County have yet to realize its benefits
suggesting that the industry is still in its infancy. Due to the realization that the industry has struggled,
we spent some time looking for ideas that could help make our recommendation a success.
10
The Telehealth Technical Assistance Manual is a planning guide, focusing on ensuring success for rural
communities and migrant health centers. xv It recognizes that the Telehealth industry has been
struggling and points out that one of the main reasons for its failure is that many of the Telehealth
programs terminate after only a few years. While the programs provide many quality services and have
served many people, they often end prematurely, and these failures have been detrimental to the
industry as a whole. Therefore, the guide suggests using the Seven Steps of Telehealth Planning for
Program Success as seen in Appendix 3.
Over the past 10 weeks, we have explored to some extent each of these seven steps in our quest to
provide a recommendation to Morgan County. The heart of this exploration revolved around
determining Morgan County’s need for Telehealth services, discovering the possible Telehealth
applications that could be utilized to serve this need, and determining an infrastructure that could
ultimately support a county-wide Telehealth initiative. Additionally, during this exploration we realized
that all of this would not be possible overnight, but that there were things we could implement now and
at various stages that could help make the initiative a success. Therefore, we are suggesting a threephase approach to the county-wide Telehealth network. The primary reasons behind this phased
approach were the following:

Morgan County has a current need for Telehealth services and there are some technologies that
could be deployed today through the existing Plain Old Telephone System(POTS)

More sophisticated Telehealth applications require more than POTS, but the current broadband
infrastructure in Morgan County is very limited.

In order to absorb the cost of a county-wide broadband network, it is likely that financial
resources will need to be pooled together in order to fund this initiative.

Time to gain acceptance. Our survey results indicate that many are unaware of the values of
Telehealth. A staged approach will allow Morgan County to prove this value along the way, by
evaluating progress and making changes during subsequent phases that could help to gain a
greater level of acceptance. Not only is acceptance needed from providers and patients, but
also by the community as a whole in understanding the need for Telehealth and a broadband
telecommunications infrastructure.

There are national programs and grants that could provide funding to Morgan County, but the
funding from these programs may not be available immediately.
By approaching this initiative in phases, it allows immediate use and benefits of Telehealth, and
opportunities to market and provide awareness for the need for broadband connectivity and Telehealth
services, helping to pool county resources together. Additionally, it allows time for national initiatives to
mature so that external resources may be available to help fund county-wide deployment as well.
11
Rural Healthcare Pilot Program
On November 19, 2007, the FCC initiated this program in order to facilitate the creation of a nationwide
broadband network for the purposes of healthcare, aimed at connecting public and private healthcare
providers in rural and urban areas of the country. Through this initiative, 69 counties in 42 states have
been selected to receive $417 million to provide resources to cover costs associated with:xvi





Network Design Studies
Construction and Network Deployment
Transmission Facilities
Recurring and Non-recurring costs of advanced telecommunication services needed to connect
to the public internet
Costs to connect to dedicated nationwide backbones including Internet2 or National
LamdaRail(NLR)
In May, 2007, the Adena Health System and O’Bleness Health System joined to request funding to create
the Southern Ohio Healthcare Network. This network is proposed to service 15 rural counties in
southern Ohio, 10 of which are some of the most impoverished counties in Ohio. The network will also
provide services to over 50 healthcare facilities, along with serving 17 areas of Ohio that have been
designated as Health Professional Shortage Areas (HPSA). The network design specifies the purchase of
2 fiber optic rings, aimed at connecting the largest concentration of healthcare facilities throughout
southern Ohio. As shown in the figure below, Morgan County is one of the HPSA’s that could be
serviced by Ring 2.xvii
Ring1: South-central Ohio: 175 Miles of fiber optic cable, establishing 5 health points-ofpresence (H-POP), providing a Gigabit Ethernet (1Gbps) connection to facilities.
Ring2: Southeastern Ohio: 140 miles of fiber optic cable, establishing 3 health points-ofpresence (H-POP), providing a 1Gbps connection to these facilities.
12
While the FCC approved the application for the Southern Ohio Healthcare Network, so far the progress
of the initiative is somewhat unclear. While Morgan County was included in the initial plan for the
network, progress has been slow and the likelihood that the network will actually service Morgan
County is somewhat unclear. Through our discussion with Pankaj Shah, the Senior Director of
Technology Infrastructure at the Ohio Supercomputer Center, we learned that Morgan County has not
officially been amended to the application. We contacted Chris Chapman, from the Ohio Office of
Information Technology and the Appalachian Ohio Broadband Taskforce, and he informed us that in
order to submit the amendment, Morgan County must simply designate a central location for
connection to the network.
While Morgan County could still benefit from Telehealth technologies without the aid of this grant, the
funding could provide valuable resources in providing for last-mile technologies making county-wide
broadband access, and Telehealth services a reality. Through our discussion with Rick Shriver, Morgan
County Commissioner, we have learned that the installation of a T1 connection has begun at the Morgan
County Learning Center, which is co-located with the Morgan County Family Health facility. With
expected completion by fall, this would be a desirable location to allocate as the central point of
connection to the Southern Ohio Healthcare Network, and a formal amendment should be initiated as
soon as possible.
Once the amendment is in place, the actual outcome of the network could take some time. As
mentioned previously, our phased-in approach should allow enough time for the completion of the
Southern Ohio Healthcare Network that could ultimately provide millions of dollars in funding to help
with costs associated with the county-wide deployment of a broadband Telehealth network.
Phase 1: In-Home Health Monitoring
Services Provided
Given the fact that broadband connectivity is not available throughout Morgan County, phase one
utilizes Telehealth technologies that do not require broadband connectivity. Through our analysis of
Telehealth applications, we learned that there are many applications that simply require the Plain Old
Telephone System (POTS), which could easily be incorporated into the existing healthcare infrastructure
in Morgan County. Experimentation with these technologies will provide awareness to the idea of
Telehealth, and could help to support the need for additional, more sophisticated services in the future.
Telenursing is an application that could easily be deployed during this phase. Most importantly, this
type of application will address many of Morgan County’s current health concerns related to chronic
disease , given that over 40% of the population is over the age of 45.
Alliance/Partnership
The Remote Nurse, provided by Interim Healthcare, is a promising device that could be used during this
phase. Interim Healthcare currently operates offices in Coshocton and Muskingum counties, and has
already witnessed success of the Remote Nurse in Coshocton County. This local presence will likely
13
provide for a close relationship with the supplier that could help to ensure success of this phase. Given
Interim’s experience with the Remote Nurse, barriers to success could be mitigated throughout the
process to ensure success of the technology in Morgan County. Additionally, the risks involved are
minimal since Interim Healthcare takes the responsibility for setup, training, and initial marketing of the
device. Morgan County should, however, seek to create awareness in the community by performing
public relation campaigns.
We recommend creating a relationship with Interim Healthcare and to deploy a Morgan County pilot of
the Remote Nurse. Interim has a supply of devices that it loans to patients at no cost. We recommend
10-25 participants in Morgan County. This size pilot could easily be managed to ensure success.
Ultimately, these participants will be the ones that will most effectively promote the use of the devices
in the future, so we suggest starting with a small group to ensure success.
Recommended Technology
Morgan County could start this initiative immediately, without the need for a change to its current
telecommunications infrastructure. While Interim Healthcare does have a supply of devices on-hand, if
Morgan County should require additional devices, it could purchase them at $2500 apiece.
Evaluation of Outcomes
With the local presence of Interim Healthcare, building a solid relationship with the provider should be
possible. This relationship ensures constant evaluation of the pilot. While other peripheral equipment
suppliers offer similar devices, we feel that a close relationship with Interim Healthcare will ultimately
help to make the project a success.
Phase 2: Patient/Provider Consultation
Services Provided
Through analysis of the Remote Nurse pilot, it is likely that there will be a demand for more
sophisticated Telehealth applications. While the technology in phase one is categorized as a store and
forward delivery model, applications in phase two will likely demand a real-time delivery of health
related information. This could be satisfied by the use of video conferencing equipment in the analysis
and treatment of patients. As seen in Appendix F, many devices could be used for real-time interaction
between the remote provider and the patient. Additionally, the modern Telehealth phase offers an
array of potential applications. Through our needs analysis of Morgan County, we determined that
Telepsychiatry was one particular application that requires the real-time delivery model for Telehealth,
and could be beneficial to Morgan County.
Alliance/Partnership
We recommend a partnership with the Morgan County Learning Center, co-located with the Morgan
County Family Health facility as a way to pool resources together to purchase video conferencing
14
equipment that generally costs between $5000-$10000. We envision this equipment could be shared
for educational purposes as well as remote consultations with a psychiatric provider. For instance, a
Psychiatrist in Zanesville could rent a room in the facility that could be used for remote consultations.
Morgan personnel could be utilized for training and support services, but these costs could be mitigated
by passing them onto the remote provider. Or, a provider may wish to send a remote clinician to the
facility for purposes of training and support. This decision is ultimately up to the parties involved.
Similar to our recommendation in phase 1, a partnership with a semi-local provider will help to ensure
success of this phase. Therefore, a TelePsychiatry pilot with Six County, Inc., aimed at acquiring 5-10
participants, would likely be a success. Six County, Inc already serves Morgan County through such
services as outpatient counseling, psychiatric evaluation and medication management.xviii We feel this
local presence in the community could help to market and promote awareness of the pilot, ultimately
helping to make it a success.
Recommended Technology
We recommend taking advantage of the existing T1 broadband connection that is available at the
Morgan County Learning Center. Additionally, we have determined that additional T1 connections
could be established at other locations at an approximate cost of $1000 per month. We feel this gives
the ability to grow during this phase should the program be an immediate success. Growth during this
phase would demand the purchase of additional video conferencing equipment given that the initial
equipment is shared with the learning center. However, we envision that a provider would assume this
cost if they wanted to pursue an expansion of their practice.
Additionally, to fuel the awareness for the need for broadband connectivity in Morgan County, we also
recommend another satellite deployment be considered for the municipality of Malta. In preparation
for the likelihood that county-wide broadband is available in the future, it is necessary for Morgan
County to prove this need. As shown in Appendix A, broadband connectivity is currently available to
only a fraction of the county. While the TelePsychiatry pilot will foster awareness for the need for
broadband connectivity, an additional satellite project similar to Chesterhill could also add to this
momentum. One of the greatest results of the Chesterhill project was that it brought awareness to
telecommunications companies that there is a need, demand, and ultimately a profitability model for
rural areas.xix Malta, with a population of approximately 700, could add valuable support for the need
for broadband connectivity.xx In preparation for phase three, it is in the county’s best interest to
promote this awareness as much as possible.
Evaluation of Outcomes
Morgan County could easily formulate a plan for communication and feedback with Six County, Inc.
Given its current knowledge of needs in Morgan County, Six County, Inc. is likely to provide valuable
feedback as to the challenges and success of the pilot, ultimately ensuring the success of the initiative.
15
Phase 3: County-Wide Broadband Telehealth
Services Provided
Through use of new Telehealth technologies using broadband access in town, and an introduction of
broadband services to the Malta municipality through an additional satellite initiative, awareness of the
need for county-wide broadband access is likely to be realized. Additionally, other broadband initiatives
in the state are likely to progress and the financial resources could possibly be available. For instance,
the development of the Coshocton wireless mesh initiative and a template of success may be available
for other rural communities to follow. Additionally, the Southern Ohio Healthcare Network is likely to
be in place and since Morgan County took the initiative to ensure its presence in the network,
connection to ring 2 may be a possibility for the county. Therefore, the resources and awareness of
need could make county-wide broadband Telehealth a reality.
While phase one and two promoted specific applications to promote store and forward, and real-time
Telehealth initiatives, phase three allows for expansion of such technologies into the patient’s homes.
For instance, remote education could be an application utilized during this phase through remote
educational classes regarding pandemic training, disease prevention and natural disaster planning.
Additionally, an expansion of the TelePschiatry pilot could now experiment with in-home psychiatric
consultations using a Webcam. The possibilities are endless given county-wide broadband connectivity,
so the decision is ultimately up to Morgan County.
Recommended Technology
As shown in Appendix E, we have completed analysis of technologies that could be used for last-mile
broadband connectivity to Morgan County. Regardless of whether this infrastructure is ultimately
connected to the Southern Ohio Healthcare network, we have chosen a technology plan that seems
economical for the rural landscape of Morgan County.
In phase two, with the addition of the satellite infrastructure in Malta, telecommunication providers are
likely to realize a profitability model for Morgan County. Therefore, the county will benefit from this
competitive landscape where more than one telecommunication company has a desire to bid on such a
project. Ultimately, this will provide cost savings to Morgan County in lower prices for equipment used
for county-wide deployment. Should funding from the Southern Ohio Healthcare Network be available,
these costs would be covered by that initiative. If, however, such funding is not available, Morgan
County has potentially fostered enough support to fund the initiative on its own.
Morgan County’s marketing and outreach during phases one and two will likely to have spurred enough
interest in pooling Government and commercial resources together to make broadband connectivity a
reality for all of Morgan County. Specifically, the joint relationship with the Morgan County Learning
Center during the TelePsychiatric pilot, and the addition of a satellite initiative in Malta have proven that
broadband connectivity could help to make Morgan County a better place to live and work.
16
During our technology analysis for this phase, we first reviewed the existing broadband infrastructure in
Morgan County, determining the technologies that could be added to make county-wide deployment
possible. While cable, DSL, satellite, and a T1 are currently available in parts of Morgan County, the
majority of the county has no access. Additionally, the county-wide deployment of these technologies is
unlikely due to the costs associated with deploying them in rural areas. However, wireless technologies
like wireless mesh, and Wi-Max could be used.
After considering both technologies, we have concluded that a wireless mesh infrastructure is likely to
be the best approach. While Wi-Max is a great potential for rural areas, we feel that the maturity of the
technology may not meet the time requirements for Morgan County. Additionally, we have completed
research on the Coshocton wireless mesh initiative and feel that the similarities between the counties
make this type of initiative an economical choice for Morgan County as well.
Initial plans for the Coshocton mesh initiative make use of 3 MARCS towers that reside in the county, in
addition to 2 MARCS towers that are in a neighboring county. Recently, they have begun leasing these
towers for $400 per month. While this cost could be viewed as a risk to the project, Coshocton has been
creative in how they plan to transfer this cost to the telecommunications company that ultimately builds
the wireless mesh infrastructure. The beauty of this type of plan is that the towers can be used even
before the mesh network is in place. Since they are just beginning the RFP process for the wireless
infrastructure, it may be awhile until the network is in place. However, other entities in Coshocton can
benefit from the lease of the towers including EMS, Fire, and other entities requiring high structures for
deployment of communication equipment used for emergencies.
Alliance/Partnership
Morgan County could easily employ the similar plan. As shown in Appendix A, a MARCS tower is already
in place in Union township. Neighboring counties of Washington, Perry, and Athens could be explored
to find additional MARCS towers that could be utilized for the initiative. Making use of these towers will
help to entice telecommunication companies to bid on the project since high structures, required for the
wireless mesh equipment, will be available. An RFP process should be initiated requesting proposals
from these companies for an overall cost analysis of what it would take to make wireless mesh available
county-wide. As mentioned previously, the outreach and awareness resulting from the pilots in phase
one and two, will likely help to make this RFP process more competitive, resulting in lower quotes to
Morgan County.
While the telecommunications company that is ultimately selected for the project would manage the
infrastructure, we envision some support and/or training will be needed at the county level in order to
ensure the success of the project. Since the wireless communication equipment will reside on the
leased MARCS tower, it is likely that a Morgan County representative would be a needed liaison
between the telecommunications provider and the owners of the MARCS towers. For instance, if there
are challenges in getting the equipment installed on the tower, Morgan County’s existing relationship
with the state agencies that actually own the towers could make it easier to resolve such issues.
17
Similar to previous phases, we suggest a controlled rollout of the wireless mesh network. This could be
accomplished by utilization of the MARCS tower within the county to deploy wireless mesh to a portion
of the county, as opposed to county-wide deployment at the start. This controlled approach could
ultimately help to make the project a success, as there will be opportunities to adjust the technology
plan should that be needed.
Evaluation of Outcomes
Given the controlled rollout of the initiative, there will be time to solicit feedback from all entities
involved with the project. There could be specific geographic and line-of-site challenges for a particular
area of the county, and this could be addressed throughout the rollout, and ultimately prevented for
subsequent areas of deployment.
Conclusion
During our journey over the past 10 weeks, while our focus was on providing a recommendation to
Morgan County for a county-wide Telehealth network, what we discovered was that our analysis and
recommendation will likely solve many challenges in Morgan County. We became aware of the
disparities in the county not only from the perspective of healthcare, but also with respect to the lack of
access to modern technologies that could provide value to all people in Morgan County. Given this
broad potential, we concluded that a phased-in approach that would allow the county to mature with
the technology, foster community-wide acceptance, and to bring resources together that could
ultimately make the project a success. Additionally, it allows time for federal funding programs to
mature that could potentially fund the majority of the cost of the initiative. We believe our phased-in
approach will provide the foundation that Morgan County needs to support Telehealth technologies of
today, as well as technologies not yet discovered. Perhaps one day Morgan County citizens will have the
capability to constantly monitor their health through the use of mobile devices in their cars and homes.
This monitoring could prevent the type of chronic diseases that are so prevalent today. With a great
foundation, Morgan County will undoubtedly experience value from Telehealth services today and of
the future.
18
Appendix A
19
Appendix B
Seven Steps of Telehealth Planning for Program Success
1. A Needs Evaluation
This is the most critical step in Telehealth planning. Decisions made in this step will affect the entire
program. You must answer the question: “Why do we need Telehealth?” Begin by considering the
patients that will be served. An excellent way to determine the needs of patients and providers is to
conduct focus groups and perform surveys with each group. Advisory groups and a board of directors
is another way to monitor progress of any new program. Join other regional organizations to gain
insight to other successful initiatives.
2. A Care Service Plan
In this step you should consider the needs identified in step 1, determine which services will be
offered, and how they will be delivered using Telehealth. You must consider the source of medical
services through Telehealth, how those services will be delivered, the location of the providers, the
location of the patients and the guidelines and protocols for delivering these services. You must
consider the necessary Telehealth technology features used in delivering the services, such as quality
of audio & video transmission, special instruments to view the patient and the equipment to measure
physiological parameters. The focus needs to be on general features and specifications and not in
terms of specific vendors or equipment models. Develop relationships with health service facilities,
major employers, and organizations such as regional universities, and medical centers.
3. A Business Plan
This is a critical step that is often omitted but is necessary to predicting sustainability of the program.
Identify all possible increases in cost, reductions in cost and increases in revenue that will be impacted
by the Telehealth program. Buy technology that meets the needs rather than buying equipment and
then trying to make it fit your situation. Consider hidden costs such as training. Include a marketing
plan as well as a long term sustainability plan.
4. A Technology Plan
Sometimes technology is planned first and all other steps are neglected. This will increase the
probability that the project will fail and the equipment will be abandoned within a short time. A
thorough and objective technology plan based on realistic needs, a care service plan and a business
plan can increase the probability of long-term sustainability of a Telehealth program. The technology
planning process should begin with a review of the priority outcomes from the needs analysis. This
includes the functions needed by the patient, the functions needed by the health care provider and
the functions needed by the organization (cost & return on investment). Physicians, nurses, medical
providers, clinicians and technologists as well as administrators and patients may all contribute or be
involved in this organizational step. An experienced person who has developed Telehealth programs
is an asset to this group. Develop a list of vendors and products, including features and specifications
for consideration. Create/write a request for price/quote and invite vendors to demonstrate their
products. The organization then collectively makes the technology choice.
20
5. Personnel Training
A plan should be developed to train personnel for the arrival of the technology and for its use
with patients and providers. Personnel that could be included are patients, providers, staff
members, administrators, health educators, social workers and mental health providers.
Training may be important enough that is may need to be included in the RFP process. Change
and an introduction to a new system involves a learning curve that slows business down for a
period of time. This needs to be acknowledged, planned for, and accounted for in the business
plan.
6. Test Care and Technology Plan
The health care and technology plans need to be tested by performing a pilot program with a
limited number of patients and staff members. During this process, much will be learned from
patients, nurses, referring providers, specialty providers, and other staff members as the pilot is
implemented. At this point clinical protocols, the business plan, and other parts of the
Telehealth plan may be revised. It is much better to learn lessons with a few participants than
with large numbers.
7. An Evaluation of the Outcomes
Identify three target beneficiaries in the planning process: outcomes important to patients, providers
and the organization. All are interdependent and mutually supportive. Write goals and performance
standards to measure against. Outcome data will be important in evaluating the results, adjusting the
operation of the program and planning the future of the program.
21
Appendix C – Telehealth/Telemedicine Survey
Team 1 Sarah & Dorothy
Morgan County
Telehealth Initiative Survey
What is your Age Group?
Name (optional)
Under
20
20-30
30-40
40-50
50-65
Strongly
Agree
Over 65
Do you
have
insurance?
Do you
have a
health
issue?
Do you
use the
WEB?
Yes
Yes
Yes
No
Agree
Disagree
3
2
No
Strongly
Disagree
4
Not
Applicabl
e
1
0
1. You understand what Telehealth is.
Telehealth Provider Education
2. You would take advantage of continuing
education credit or training if offered
through a Telehealth initiative.
x
x
x
x
x
3. You are not able to travel for
training/educational purposed because of
driving distance and price of gas.
x
x
x
x
x
4. You are comfortable with Telehealth
education/training.
x
x
x
x
x
5. You believe it is a quality
education/training.
x
x
x
x
x
6. You have access to high- speed internet
connectivity.
x
x
x
x
x
7. You support a Telehealth initiative.
x
x
x
x
x
22
N
o
Telehealth Patient Education
8. You would take advantage of patient
training/ education if offered through a
Telehealth initiative.
x
x
x
x
x
9. You are not able to travel for
training/educational purposed because of
driving distance and price of gas.
x
x
x
x
x
10. You are comfortable with Telehealth
education/training.
x
x
x
x
x
11. You believe it is a quality
education/training.
x
x
x
x
x
12. You have access to high-speed internet
connectivity.
x
x
x
x
x
13. You support a Telehealth initiative.
x
x
x
x
x
15. You would take advantage of a
telemedicine
x
x
x
x
x
16. You are not able to travel for health care
because of driving distance and price of
gas.
x
x
x
x
x
17. You believe telemedicine offers quality
health care.
x
x
x
x
x
18. You have access to high-speed internet
connectivity.
x
x
x
x
x
19. You support a Telehealth initiative.
x
x
x
x
x
20. You would attend a clinic in Morgan county
if it had access to Telemedicine
associated with a major Health Care
Facility For:
x
x
x
x
x
Telemedicine
14. You trust telemedicine and believe there
are benefits to the initiative.
Routine Check-up
23
21. OB/GYN Appointments
22. Pediatric Care
x
x
x
x
x
23. Psychiatric Care
x
x
x
x
x
24. Surgery Follow-up
x
x
x
x
x
25. Dental Check-up
x
x
x
x
x
26. Blood Work
x
x
x
x
x
27. X-Rays
x
x
x
x
x
28. Additional Comments:
24
Team 1 - Morgan County Telehealth Initiative Survey
General Questions
Age Group
Under 20
20-30
30-40
40-50
50-65
over 65
1
3
2
1
3
1
11
9.09%
27.27%
18.18%
9.09%
27.27%
9.09%
100.00%
Do you Have Insurance
yes
Under 20
20-30
30-40
40-50
50-65
over 65
no
1
2
2
2
1
8
72.73%
12.50%
25.00%
25.00%
0.00%
25.00%
12.50%
1
1
1
3
27.27%
0.00%
33.33%
0.00%
33.33%
33.33%
0.00%
100.00%
Do you Have a Health Issue
yes
Under 20
20-30
30-40
40-50
50-65
over 65
no
1
2
2
12.50%
25.00%
25.00%
0.00%
2 25.00%
1 12.50%
8 100.00%
72.73%
1
1
1
3
27.27%
Do you Use the WEB
yes
25
no
0.00%
33.33%
0.00%
33.33%
33.33%
0.00%
100.00%
100.00%
Under 20
20-30
30-40
40-50
50-65
over 65
1
2
2
1
1
7
63.64%
12.50%
25.00%
25.00%
0.00%
12.50%
12.50%
87.50%
Question 1
You understand what Telehealth is?
4
3
2
1
0
5
6
0
0
0
45.45%
54.55%
0.00%
0.00%
0.00%
11 100.00%
Telehealth Provider Education Section
Question 2
You would take advantage of continuing education credit or
training if offered through a Telehealth initiative?
4
3
2
1
0
1 14.29%
6 85.71%
0
0.00%
0
0.00%
0
0.00%
7 100.00%
4
3
2
1
0
0
0.00%
4 57.14%
3 42.86%
0
0.00%
0
0.00%
7 100.00%
4
4
Question 3
You are not able to travel for training/educational purposes
because of driving distance and price of gas.
Question 4
You are confortable with Telehealth education/training.
26
57.14%
1
2
0
1
4
36.36%
0.00%
33.33%
0.00%
66.67%
0.00%
33.33%
133.33%
100.00%
3
2
1
0
3 42.86%
0
0.00%
0
0.00%
0
0.00%
7 100.00%
4
3
2
1
0
3 42.86%
4 57.14%
0
0.00%
0
0.00%
0
0.00%
7 100.00%
4
3
2
1
0
5 71.43%
2 28.57%
0
0.00%
0
0.00%
0
0.00%
7 100.00%
4
3
2
1
0
5 71.43%
1 14.29%
1 14.29%
0
0.00%
0
0.00%
7 100.00%
4
3
2
1
0
5 71.43%
1 14.29%
1 14.29%
0
0.00%
0
0.00%
7 100.00%
Question 5
You believe it is a quality education/training
Question 6
You have access to high-speed internet connectivity.
Question 7
You support a Telehealth initiative.
Question 7
You support a Telehealth initiative.
27
Telehealth Patient Education Section
Question 8
You would take advantage of education/training if offered
through a Telehealth initiative?
4
3
2
1
0
4 36.36%
6 54.55%
1
9.09%
0
0.00%
0
0.00%
11 100.00%
4
3
2
1
0
0
0.00%
6 54.55%
5 45.45%
0
0.00%
0
0.00%
11 100.00%
4
3
2
1
0
9 81.82%
1
9.09%
1
9.09%
0
0.00%
0
0.00%
11 100.00%
4
3
2
1
0
2 18.18%
9 81.82%
0
0.00%
0
0.00%
0
0.00%
11 100.00%
Question 9
You are not able to travel for training/educational purposes
because of driving distance and price of gas.
Question 10
You are comfortable with Telehealth education/training.
Question 11
You believe it is a quality education/training
28
Question 12
You have access to high-speed internet connectivity.
4
3
2
1
0
5 45.45%
4 36.36%
2 18.18%
0
0.00%
0
0.00%
11 100.00%
4
3
2
1
0
4 36.36%
5 45.45%
2 18.18%
0
0.00%
0
0.00%
11 100.00%
4
3
2
1
0
3 30.00%
7 70.00%
0
0.00%
0
0.00%
0
0.00%
10 100.00%
4
3
2
1
0
4 36.36%
6 54.55%
1
9.09%
0
0.00%
0
0.00%
11 100.00%
Question 13
You support a Telehealth initiative.
Telemedicine Section
Question 14
You trust telemedicine and believe there are benefits to the
initiative.
Question 15
You would take advantage of telemedicine.
29
Question 16
You are not able to travel for health care because of driving
distance and price of gas.
4
3
2
1
0
1
9.09%
5 45.45%
5 45.45%
0
0.00%
0
0.00%
11 100.00%
4
3
2
1
0
9 81.82%
2 18.18%
0
0.00%
0
0.00%
0
0.00%
11 100.00%
4
3
2
1
0
7 63.64%
4 36.36%
0
0.00%
0
0.00%
0
0.00%
11 100.00%
4
3
2
1
0
8 72.73%
2 18.18%
1
9.09%
0
0.00%
0
0.00%
11 100.00%
Question 17
You believe telemedicine offers quality health care.
Question 18
You have access to high-speed internet connectivity.
Question 19
You support a Telehealth initiative.
You would attend a clinic in Morgan county if it had access to
Telemedicine associated with a major health care facility for:
Question 20
Routine Check-up
30
4
3
2
1
0
6 54.55%
4 36.36%
1
9.09%
0
0.00%
0
0.00%
11 100.00%
4
3
2
1
0
4 36.36%
4 36.36%
1
9.09%
1
9.09%
1
9.09%
11 100.00%
4
3
2
1
0
4 36.36%
3 27.27%
3 27.27%
1
9.09%
0
0.00%
11 100.00%
4
3
2
1
0
4 36.36%
3 27.27%
2 18.18%
2 18.18%
0
0.00%
11 100.00%
Question 21
OB/GYN
Question 22
Pediatric Care
Question 23
Psychiatric Care
Question 24
Surgery Follow-up
4
3
2
1
0
31
4
7
0
0
0
36.36%
63.64%
0.00%
0.00%
0.00%
11 100.00%
Question 25
Dental Check-up
4
3
2
1
0
4 36.36%
6 54.55%
1
9.09%
0
0.00%
0
0.00%
11 100.00%
4
3
2
1
0
4 36.36%
7 63.64%
0
0.00%
0
0.00%
0
0.00%
11 100.00%
4
3
2
1
0
4 36.36%
7 63.64%
0
0.00%
0
0.00%
0
0.00%
11 100.00%
Question 26
Blood Work
Question 27
X-Rays
Comments:
1) how else could a person who lives in a poor county receive medical treatment from one with
exceptional experience and background
2) fabulous idea!
3) would take advantage is needed
4) firm believer of/in the use of technology; however, there are some elements such as the relationship
you build and the level of comfort you have with your physician. In some cases I would be skeptical even
32
with the advancements with distance learning/education
5) when thinking in general, clinical, check-ups, x-rays, and blood screenings - no matter where you are,
it would be beneficial to patients that do not have mean to travel or need emergency care
6) with emergency care, a specialist could be contacted in real time from anywhere
7)would want my primary care physician in some situations
8)personal intervention - understand can be some interaction through technology put would rather have
personal attention
9)ob/gyn - not unless needs emergency /special care
10) would not want to use it for pediatric care…want the best for children not Telehealth
11)sounds great!
12) would use Telehealth education for health care management courses
13) would rather have in class education
14) current problems with Telehealth applications at health care provider…slow internet connection….
data not compatible
15) works well at the hospital with x-ray reading
16) would rather know that physician has quality education not distant education
17) would rather have personal attention of physician..trust person relationship …very important
18) hospital has good results with Telehealth
33
Appendix D: Telecommunications Technology
POTs
Technology
Description
Plain Old Telephone – POTs
Maturity
Very Mature
Modems have been transmitting data since the 1960s.
Modem speeds went through a series of steps at approximately two-year intervals:
Traditional phone service (sometimes called POTS for "plain old telephone service") connects your
home or small business to a telephone company office over copper wires that are wound around each
other and called twisted pair. Traditional phone service was created to let you exchange voice
information with other phone users and the type of signal used for this kind of transmission is called an
analog signal. An input device such as a phone set takes an acoustic signal (which is a natural analog
signal) and converts it into an electrical equivalent in terms of volume (signal amplitude) and pitch
(frequency of wave change). Since the telephone company's signaling is already set up for this analog
wave transmission, it's easier for it to use that as the way to get information back and forth between
your telephone and the telephone company. That's why your computer has to have a modem - so that
it can demodulate the analog signal and turn its values into the string of 0 and 1 values that is called
digital information.
Because analog transmission only uses a small portion of the available amount of information that
could be transmitted over copper wires, the maximum amount of data that you can receive using
ordinary modems is about 56 Kbps (thousands of bits per second). The ability of your computer to
receive information is constrained by the fact that the telephone company filters information that
arrives as digital data, puts it into analog form for your telephone line, and requires your modem to
change it back into digital. In other words, the analog transmission between your home or business
and the phone company is a bandwidth bottleneck.









Alternatives
Risks
300 bps - 1960s through 1983 or so
1200 bps - Gained
popularity in 1984 and
1985
2400 bps
9600 bps - First
appeared in late 1990
and early 1991
19.2 kilobits per
second (Kbps)
28.8 Kbps
33.6 Kbps
56 Kbps - Became the standard in 1998
ADSL, with theoretical maximum of up to 8 megabits per second (Mbps) Gained popularity in 1999
Cable, DSL, T1, Wireless
POTs are commonly used for inexpensive intermittent communication between a network and
geographically isolated computers. Although inexpensive, POTs are very slow in transmission of data,
large files can be difficult to transmitted, and the phone line is shared with voice and data, meaning
the data line is not always on.
Costs
Purchase or rental of modem and phone service. Typical home phone bill maybe $35-$45 per month.
References
Home phone bill - http://communication.howstuffworks.com – Novell primer
Applications
Used by both patients/trainees and providers
34
DSL
Technology
Description
Digital Subscriber Line - DSL
DSL is a very high-speed connection that uses the same wires as a regular telephone line.
The service is not available everywhere.
DSL (Digital Subscriber Line) is a technology for bringing high-bandwidth information to homes
and small businesses over ordinary copper telephone lines. xDSL refers to different variations
of DSL, such as ADSL, HDSL, and RADSL. Assuming your home or small business is close
enough to a telephone company central office that offers DSL service, you may be able to
receive data at rates up to 6.1 megabits (millions of bits) per second (of a theoretical 8.448
megabits per second), enabling continuous transmission of motion video, audio, and even 3-D
effects. More typically, individual connections will provide from 1.544 Mbps to 512 Kbps
downstream and about 128 Kbps upstream. A DSL line can carry both data and voice signals
and the data part of the line is continuously connected.
Advantages:




You can leave your Internet connection open and still use the phone line for voice
calls. Always on.
The speed is much higher than a regular modem
DSL doesn't necessarily require new wiring; it can use
the phone line you already have.
The company that offers DSL will usually provide the
modem as part of the installation.
Disadvantages:

A DSL connection works better when you are closer to
the provider's central office. The farther away you
get from the central office, the weaker the signal
becomes.

The connection is faster for receiving data than it is for
sending data over the Internet.
Maturity
Mature
DSL Modems have been transmitting data since 1998.
Alternatives
Risks
With DSL's distance limitation and lower availability, there are two major alternatives to DSL -- cable
and wireless.
Cable isn't limited by distance like DSL -- cable wires reach most neighborhoods, and signal strengths
don't weaken over long distances. While DSL allows you to use the telephone and Internet
simultaneously, cable lets users watch television and surf the Internet at the same time. Many cable
companies are also beginning to bundle services with cable TV, Internet and digital telephone on one
bill. Although cable and DSL speeds are about the same, the one disadvantage with cable is bandwidth
-- connection speeds can slow down if too many people are using a cable service at the same time
Serviced is not available everywhere. Can serve from 1-15 people or computers based on average use.
Costs
From $50 to $250 per month
References
http://www.t1shopper.com - http://communication.howstuffworks.com – Novell primer
Applications
Used by both patients/trainees and providers.
35
Cable
Technology
Description
Cable Modem
Many people who have cable TV can get a high-speed connection to the Internet from their
cable provider. Cable modems don't connect to your phone line, they connect to the same
coaxial cable that you connect your television to. The idea behind cable modems is to allow
faster direct access to the Internet via your cable company. Cable modems compete with
technologies like asymmetrical digital subscriber lines (ADSL). Unlike ADSL, its performance
doesn't depend on distance from the central cable office. A digital CATV system is designed to
provide digital signals at a particular quality to customer households. On the upstream side,
the burst modulator in cable modems is programmed with the distance from the head-end, and
provides the proper signal strength for accurate transmission. Each television signal is given a
6-megahertz (MHz, millions of cycles per second) channel on the cable. The coaxial cable
used to carry cable television can carry hundreds of megahertz of signals, which allows you to
view many channels and receive data at the same time. Connection is always on.
All cable modems contain certain key components:
 A tuner
 A demodulator
 A modulator
 A media access control (MAC) device
 A microprocessor
Maturity
Mature - Cable Modems for TV and transmitting data gained in high usage in the 1990’s.
Alternatives
Risks
DSL and wireless. DSL speeds are about the same as cable.
Service is not available everywhere. Availability is limited in Morgan County. – Time Warner is
provider. As new users, especially heavy-access users, are connected to the channel, you will have to
share that bandwidth, and may see your performance degrade as a result.
It is possible that, in times of heavy usage with many connected users, performance will be far below
the theoretical maximums.
Costs
From $30 - $60 per month depending on the usage and speed. 256K to 4.0M.
References
Various Cable Providers - http://communication.howstuffworks.com – Novell primer
Applications
Most Telehealth applications for both provider and patient/trainee. If the application requires a
phone line, cable cannot be used.
36
T1
Technology
Description
T1 - The name T1 came from the carrier letter assigned by AT&T to the technology. Essentially, the "T" is a part
number that was assigned by AT&T. T-carrier was next letter available and T1 is the first level in the hierarchy.
The phone company moves nearly all voice traffic as digital rather than analog signals. Your analog line gets
converted to a digital signal by sampling it 8,000 times per second at 8-bit resolution (64,000 bits per second).
Nearly all digital data now flows over fiber optic lines, and the phone company uses different designations to talk
about the capacity of a fiber optic line.
If your office has a T1 line, it means that the phone company has brought a fiber optic line into your office (a T1
line might also come in on copper). A T1 line can carry 24 digitized voice channels, or it can carry data at a rate of
1.544 megabits per second. If the T1 line is being used for telephone conversations, it plugs into the office's phone
system. If it is carrying data it plugs into the network's router.
A T1 line can carry about 192,000 bytes per second -- roughly 60 times more data than a normal residential
modem. It is also extremely reliable -- much more reliable than an analog modem. Depending on what they are
doing, a T1 line can generally handle quite a few people. For general browsing, hundreds of users are easily able
to share a T1 line comfortably.
A T1 line is available almost anywhere unlike DSL. The connection is always up and running 24/7 guaranteed. T1
lines are a higher quality internet service providing a firm foundation for other advanced applications such as
email, web servers, multi-user VPN, Citrix, or VOIP services. T1 connections can decrease expensive phone bills by
placing up to 23 phone lines with dedicated long distance service on the T1 line in addition to internet service.
A large company needs something more than a T1 line. The following list shows some of the common line
designations:








DS0 - 64 kilobits per second
ISDN - Two DS0 lines plus signaling (16 kilobytes per second), or 128 kilobits per second
T1 - 1.544 megabits per second (24 DS0 lines)
T3 - 43.232 megabits per second (28 T1s)
OC3 - 155 megabits per second (84 T1s)
OC12 - 622 megabits per second (4 OC3s)
OC48 - 2.5 gigabits per seconds (4 OC12s)
OC192 - 9.6 gigabits per second (4 OC48s)
Maturity
Mature – T1 lines gained in popularity when the internet took off in the 1990s Before then, they were used by
larger businesses and telephone company central offices as a means to transport voice traffic between locations.
Alternatives
Risks
Cable, DSL and wireless.
Costs
A T1 line might cost between $550 and $1,200 per month depending on who provides it and where it goes. The
other end of the T1 line needs to be connected to a web server, and the total cost is a combination of the fee the
phone company charges and the fee the ISP charges.
The line speed is always consistent, but the payload can vary greatly. Expensive solution. Most reliable.
T3/DS3 can cost between $7500 and $14,000 per month. Used when T1 is not enough. Need ability to quickly
increase your data capacity up to 45 Mbps or up to 650+ dedicated phone lines. More cost effective than bonding
multiple T1 lines. Providers: Verizon or AT&T
References
http://www.t1shipper.com - http://communication.howstuffworks.com – Novell primer http://en.wikipedia.org/wiki/Digital_Signal_1 -
Applications
All Telehealth and support applications for both patient/trainee and provider.
37
Satellite
Technology
Description
Satellite
Maturity
Fairly new gained popularity in past 10 years. HughesNet has been in satellite business for 10 years,
competition less.
Alternatives
Risks
T1, Cable, DSL and wireless.
Costs
Affordable: Small office $90, Business Internet up to 2 Mbps: $181, Business Internet 400: $407 per
month
Installation from $2000 To $3000.
Additional services increase monthly bill
HugesNet and Wild Blue are possible providers
http://www.gsa.hughesnet.com - http://communication.howstuffworks.com – Novell primer http://www.getdsltoo.com/HughesNet-vs-WildeBlue.asp?gclid=CIe6ku-DkJMCFQFylgod7CmChA
References
Applications
Satellite Internet Service, is the one High Speed Internet Service that is available
anywhere. As long as one has electricity and
(in North America) a clear view of the
southern sky, satellite broadband should
be available. Satellite Internet service
operates independently of telephone or
cable networks. Download speeds for
residential Satellite Broadband Internet
are typically 500-1000 Kbps (Kilobytes
per second) or about 10-20 times faster
than a 56K modem. Upload speeds are
generally 100 - 256 Kbps. Satellite
Broadband Internet is not ideal for
consumers who require highly responsive
High Speed Internet Service such as that
required for online games or stock trading
since there is a slight delay during
transmissions. Satellite Internet services are used in locations where terrestrial Internet
access is not available and in locations which move frequently. Internet access via satellite
is available worldwide, including vessels at sea and mobile land vehicles.
Must have clear view of satellite, flexible but not always dependable, storms block signals- no service.
Patient/trainees as well as providers.
38
Broadband over Power Lines
Technology
Description
Maturity
BPL - Broadband over Power Lines
Broadband over Power Line is a technology that allows Internet data to be transmitted over utility
power lines. In order to make use of BPL, subscribers use neither a phone, cable or a satellite
connection. Instead, a subscriber installs a modem that plugs into an ordinary wall outlet and pays a
subscription fee similar to those paid
for other types of Internet service.
Special devices attached to existing
electric poles and transformers then
send a wireless signal into homes
using Wireless Fidelity (Wi-Fi)
technology and devices. This
technology could be particularly
promising in less populous areas
where high-speed Internet access
has lagged
This new service is still in it’s infancy,
permits:
 broadband internet data to use
standard high-voltage power lines
 use any electrical outlet and instantly have access to high speed internet
 combination of technological principles of radio, wireless networking and modems Access to
anyone that has Electric service
 Could be less expensive for some backbone initiatives
 Maybe a good solution for Rural Access
Infancy Stages, around about 3 years. Motorola offers interference-free service
Alternatives
Risks
T1, Cable, DSL and Satellite
Costs
Test market in North Carolina - The service costs $19.95 a month for the first three months
and $39.95 per month thereafter. Only about 500 homes will have the opportunity to
participate in this high-speed service.
References
http://communication.howstuffworks.com – http://en.wikipedia.org/wiki/Power_line_communication
http://www.progress-energy.com/aboutus/news/article.asp?id=8362
Applications
Patient/trainees as well as providers.
Electric Line Noise (interference) is a problem. Technology is cutting-edge and costs are sketchy
39
Mesh
Technology
Description
Mesh
Wireless mesh networks,
an emerging technology,
may bring the dream of a
seamlessly connected
world into reality.
Wireless mesh networks
can easily, effectively and
wirelessly connect entire
cities using inexpensive, existing technology. Traditional networks rely on a small number of
wired access points or wireless hotspots to connect users. In a wireless mesh network, the
network connection is spread out among dozens or even hundreds of wireless mesh nodes
that "talk" to each other to share the network connection across a large area.
The biggest advantage of wireless mesh networks -- as opposed to wired or fixed wireless
networks -- is that they are truly wireless. Wireless mesh networks advantages include:









Using fewer wires means it costs less to set up a network, particularly for large areas of
coverage.
The more nodes you install, the bigger and faster your wireless network becomes.
They rely on the same WiFi standards (802.11a, b and g) already in place for most
wireless networks.
They are convenient where Ethernet wall connections are lacking -- for instance, in
outdoor concert venues, warehouses or transportation settings.
They are useful for Non-Line-of-Sight (NLoS) network configurations where wireless
signals are intermittently blocked. For example, in an amusement park a Ferris wheel
occasionally blocks the signal from a wireless access point. If there are dozens or
hundreds of other nodes around, the mesh network will adjust to find a clear signal.
Mesh networks are "self configuring;" the network automatically incorporates a new
node into the existing structure without needing any adjustments by a network
administrator.
Mesh networks are "self healing," since the network automatically finds the fastest and
most reliable paths to send data, even if nodes are blocked or lose their signal.
Wireless mesh configurations allow local networks to run faster, because local packets
don't have to travel back to a central server.
Wireless mesh nodes are easy to install and uninstall, making the network extremely
adaptable and expandable as more or less coverage is needed.
Maturity
New emerging technology – more than 81 cities have installed mesh networks in US.
Alternatives
Risks
T1, DSL, Satellite, Cable
Not available
Costs
Not available
References
http://communication.howstuffworks.com/how-wireless-mesh-networks-work1.htm
Applications
Used by both patients/trainees and providers.
40
Wireless Infidelity(Wi-Fi)
Technology
Description
Wireless Infidelity(Wi-Fi)
Given their ease of use, Wi-Fi technologies should be considered for the final stages of last mile access
to Morgan County. Since this technology allows for short range connections, it could be implemented
within a home, a clinician office or a personal mobile device such as a cellular phone. Wireless
connectivity provides the following benefits:

File Sharing and Storing: Gives more flexibility than using external media. Files could include




photos, audio, and documents. Storing of digital media files to other devices is also possible wirelessly
through a Wi-Fi hot spot.
Printer/Peripheral Sharing: Through the use of Wi-fi hotspot, it is possible to connect many computers
and devices to one single printer. Other peripherals that could be shared are scanners and web cams.
Internet Connection Sharing: multiple devices including computers, notebooks and phones can share
the same internet connection
Compatibility and Coexistence: Many PC’s, notebooks, and cell phones depend on various standards
and have hardware built into them to allow for wireless connections.
Mobility: Devices can be used anywhere within a specified area, allowing for flexibility in their use. The
user is free to move, without the need to be tied down by cables.
Maturity
The FCC made unlicensed spectrum radio wave technology available beginning in 1985. Later,
regulations were copied allowing for this technology in all major countries. The Wi-Fi Alliance provides
standards, allowing for improvement to interoperability of wireless products.
Alternatives
Risks
Cabled alternatives including T1, Cable, DSL and Satellite
Interference: with other devices using the spectrum including microwave ovens, some cordless
phones, Bluetooth and baby monitors
Network Security: Without the use of a firewall, wireless connectivity has significant security
challenges. However, there is continuous effort at trying to limit the possibilities of unwanted access.
There are standards for data encryption like the WEP encryption, in addition to better encryption
standards like Wi-Fi Protected Access (WPA).
Varying Standards: There are many different Standards that are available. Various devices commit to
different standards the most popular one being 802.11b and 802.11g. Due to the differences in the
standards, there are challenges to some of them working together. Additionally, there is a possibility
of interference with other devices using the spectrum including microwave ovens, some cordless
phones, Bluetooth and baby monitors.
Costs
Wireless Cable/DSL Router $39-$199
Wireless LAN Bridge: $69-$192
Wireless Access Point: $65-$150
http://en.wikipedia.org/wiki/Wi-Fi;
http://compnetworking.about.com/cs/wireless/f/whywirelesslan.htm
http://en.wikipedia.org/wiki/IEEE_802.11; http://www.bizrate.com/bridges_routers/networkingconnection-type--wi-fi-ieee-802.11b-/device-type--access-point/products__att148--518982__att259818--035161424-304515994__att324045--22152-.html
References
41
Wireless Interoperability for Microwave Access(Wi-Max)
Technology
Description
Wi-Max
Worldwide Interoperability for Microwave Access aims at providing wireless data exchange over long
distances. This technology is also referred to as WirelessMAN, is based on the IEEE 802.16 Standard. The
Wi-Max Forum, formed in 2001, defines WiMax as a standards-based technology that could be used to
provide wireless last mile access. Wi-Max provides for two options:
Mobile Wi-Max: Offers mobility similar to a cell phone(Example: Clinician Laptop that is portable
throughout rooms of clinic)
Fixed Wi-Max: Wireless access point is offered in one location. Benefit from no cableing, but mobility is
not offered.(Example: Clinician Desk with desktop
computer)
Other Uses:
 Connecting Wi-Fi Hotspots
 Providing Businesses a backup for wired
access.
 Replacement candidate for cellular phone
technologies like GSM and CDMA.
Bandwidth:
Wi-Max provides a shared 70Mbps connection
with all users of a given radio sector, up to a
distance of 50Km. However, data bit error
increases along with distance.
Maturity
Up and running in cities like San Francisco, Chicago, and New York, but overall is extremely limited in the
United States. Possibly by 2010, we’ll see some progress.
Alternatives
Risks
Cabled alternatives including T1, Cable, DSL and Satellite
Costs
Wi-Max system consists of two parts:
WiMax Tower: Similar to a cell phone tower. Can provide coverage to a large area up to 3000 sq. miles.
WiMax Receiver: Could be a small box or PCMCIA Card, or could be built into a laptop similar to Wi-Fi.
Costs are hard to estimate not only because vendors don't readily give cost estimates, but also because the
costs could be shared with cellular companies who have existing towers that the transmitters could be
placed.
Example Quote: Base Station costs similar to 3G/4G cellular; $40K-60K for electronics, $10-$15K for
Shelter; $10-15K for civil work and installation.
Vendors
References
AirSpan, Alvarion, Aperto Networks, Proxim, RedLine, SR Telecom, Wavesat, Wi-LAN
http://en.wikipedia.org/wiki/WiMAX; http://technology.inc.com/telecom/articles/200802/wimax.html;
http://technology.inc.com/telecom/articles/200802/wimax.html;
http://www.redorbit.com/news/technology/20306/can_new_copper_tech_break_the_access_bottleneck/;
http://computer.howstuffworks.com/wimax1.htm; WI-LINC Estimate:
lincoln.ne.gov/city/council/wilinc/final.pdf


Shared Access is deceiving and could cause degradation of signal
While 50Km is quoted as max distance, ideal range and bandwidth appear to be 10mbps
at 10Km with line of site available. Without line of site performance degrades.
42
Appendix E: Morgan County’s Telecommunications Availability
Telecommunications Description
Availability
Costs
Technology
POTS – plain old
telephone service
Provider: Embarq
DSL-digital subscriber
line
Provider: Embarq
Applications
Connection is
through phone
lines. Requires
modem. Speed: 56
kbps.
All business and
homes in Morgan
County.
$30-$60 per
month
depending on
service.
Inexpensive intermittent
communication, store
and forward
applications.
High speed
connection using
phone lines.
Requires modem.
Not available
everywhere.
Store and Forward and
Real-Time Interaction
Distance limitations.
$50-$250 per
month
depending on
service
Not available
everywhere.
$30-$60 per
month
Store and Forward and
Real-Time Interaction
Speed: 10 mbps for
download
Cable
Provider: Time Warner
Connection to
internet is through
cable TV.
If phone line is
necessary, this
technology cannot be
used.
Speed: 15 mbps for
download
T1
Provider: Embarq
Satellite
Provider: HughesNet
Fiber Optic phone
line. 192,00 bytes
per second. Line is
always available.
Available most
everywhere but
expensive
$400 - $1200 per
month
depending on
service
Store and Forward and
Real-Time Interaction
High speed internet
service. Must have
clear view of
southern sky. Not
always dependable.
Available everywhere
if clear view is present
$90-$400 per
month
depending on
service
Store and Forward and
Real-Time Interaction.
Speed: 1.5 mbps but
also depends on
service level.
43
Mesh
No Provider
Wi-Fi
Wi-Max
Wireless mesh
networks can
connect entire
communities.
Not available in
Morgan County yet
but possibility
Not Available
Store and Forward and
Real-Time Interaction.
Wireless
connectivity
designed for a small
geographic
Likely to be used in
home or offices that
have a broadband
connection.
Wireless
Cable/DSL Router
$39-$199
Wireless LAN
Bridge: $69-$192
Wireless Access
Point: $65-$150
Store and Forward and
Real-Time Interaction.
Wireless alternative
to Cable and DSL;
Can be used in rural
areas
Not yet available in
Morgan
Base Station
costs similar to
3G/4G cellular;
$40K-60K for
electronics, $10$15K for Shelter;
$10-15K for civil
work and
installation.
Store and Forward and
Real-Time Interaction
44
Appendix F: Telehealth Equipment Analysis
Video Conferencing
Technology
Description
Video Conferencing
Is a collection of interactive telecommunication technologies, allowing two or more locations to
communicate with each other through two-way video and audio transmissions. Video conferencing can
be used in many areas of a Telehealth network. The following table shows some possible applications,
along with a description of the data requirements needed for this type of deployment
Device
Description
Use
Applications
Distant
Communicator
Webcam
Webcam
mounted on
top of desktop
monitor.
Monitor
equipped with
video
conferencing
equipment
Camera
designed for
larger room
Patient InHome; Local
Clinic In Office
Telepsychiatry;
Telepsychology;
Telenursing
Webcam in office;
conference room
Patient in
Clinician office
Telepsychiatry;
Telepsychology;
Patient in
Clinician
Conference
room
Telepsychiatry,
Telepsychology
Camera and
Code
Seaparte
In clinic
examinatio
n
Telemedicin;
Telenursing
Integrated
Video
Conferencing
Technology
Set Top
Appliance
HD Video
Maturity
Alternatives
Risks
Vendors
References
Data
Requiremen
t
<1Mbps
Approximate
Costs
Access
$300
DSL, T1,
Cable
Similar Integrated
Video Conferencing
equipment
<1Mbps
$4000-$5000
DSL, T1,
Cable
Integrated monitor;
similar set-top
appliance for
conference
<1Mbps
$5000-10000
DSL, T1,
Cable
1Mbps
$10000Minimum $25000
; 2Mbps
Ideal
First generation Encoders and Decoders using the MPEG-2 Format were created in the mid-90’s. Since
then, there has been a constant evolution of the technology offering better quality given the
advancement to MPEG-4, H.264. Many vendors recognize the maturity of the H.264 standard.
Therefore, it is likely to find equipment offered for this type of technology, and at relatively competitive
pricing
Voice communication; Cell Phone Video Conferencing(3G Mobile Phones)
Voice Security; Video Security; Gaining enough capital to fund mission; Excess use due to simplicity when
a visit to clinician is in order
Misc: http://thinkofit.com/webconf/video.htm
IVCI: http://www.ivci.com/buyers
http://www.tek.com/Measurement/App_Notes/2A_18398/eng/2AW_18398_1.pdf;
http://www.ivci.com/buyers-guide-to-video-conferencing.html
45
DSL,
T1,
Cable
Peripheral Equipment
Technology
Description
Bandwidth
Telehealth Peripheral Technologies
A wide variety of devices that can be used to capture and manipulate data with the goal of transmitting it over a
telecommunications channel. This telecommunications channel could be as simple as a standard phone line, but
could also be accomplished using higher bandwidth options.
Category
Use
Bandwidth
Requirement
Devices
Applications and Costs
Image Capture
Devices
Local clinic transfer
images to remote
clinic for evaluation
Satellite,
Mobile, POTS
with Modem
Video
Camera,
Microscope,
Digital
Camera
TeleDermatology; General
Purpose
Voice
Communication
Patient to Remote
Clinician, Local
Clinic to remote
clinic
POTS
Microphone
General Purpose
Radiological
Remote clinic uses
store and forwards
results to remote
clinic
GSM,
Satellite,
Modem,
ISDN, Frame
Relay, ATM
Remote XRay, CT, and
Ultrasound
equipment
TeleRadiology
Monitoring
In-home/In-clinic
Monitoring devices
POTS
EKG, BP,
Spirometer,
peak flow
meters
Home Telehealth
Certain categories of devices could be used most effectively by the ability of the user to have a higher bandwidth
technology other than POTS. For example, the following shows the length of time for transmission of an X-Ray
image at 15MB file size using various technologies:
Type
Rate
Length of Time
GSM Mobile
9.6 Kbps
4.5 Hours
Satellite
2.4 Kbps
18 Hours
64 Kbps
40 min
28.8 Kbps
1 Hour 30 Min
Modem
Alternatives
Risks
Postal Mail; Ground Delivery
Security; Difficulties using remote devices in-home or in-clinic
46
Costs
References
www.dhs.state.mn.us/main/groups/aging/documents/pub/dhs_id_054529.pdf; www.itu.int/ITUD/univ_access/reports/155r2v2e.pdf; www.citl.org/_pdf/CITL_Telehealth_Report.pdf
i
http://www.nrharural.org/about/sub/different.html
ii
http://www.odh.ohio.gov/odhprograms/chss/hpsa/hpsa1.aspx
iii
http://tie.telemed.org/articles/article.asp?path=telemed101&article=tmcoming_nb_tie96.xml
iv
http://en.wikipedia.org/wiki/Telehealth
v
http://www.ptkasa.org/communications/video-conferencing/effectiveness-of-videoconferencing-in-longdistance-learning-21782.html
vi
http://www.dispatch.com/live/content/local_news/stories/2008/03/21/bigbil.ART_ART_03-2108_B2_Q99N7CN.html
47
vii
http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america.shtml
viii
www.diamondhealth.com/RRcorrect.pdf
ix
www.Telehealthworld.com/images/TelehealthWorldSpringEzine.pdf
x
http://news.bbc.co.uk/1/hi/health/325968.stm
xi
http://en.wikipedia.org/wiki/Teleradiology
xii
www.citl.org/_pdf/CITL_Telehealth_Report.pdf
xiii
http://en.wikipedia.org/wiki/Telemedicine
xiv
http://findarticles.com/p/articles/mi_m0PDG/is_1_4/ai_n9511665
xv
nrhapress.com/pubs/pdf/Telehealth.pdf
xvi
http://www.fcc.gov/cgb/rural/rhcp.html#faq10
xvii
http://www.fcc.gov/cgb/rural/rhcp_applications.html
xviii
http://www.sixcounty.org/whatwecando.aspx
xix
xx
http://www.osu.edu/features/2007/wiredohio/
http://en.wikipedia.org/wiki/Malta%2C_Ohio
48