The Computerworld Honors Program
Honoring those who use Information Technology to benefit society
LOCATION:
Tucson, AZ, United States

YEAR:
2008

STATUS:
Laureate

CATEGORY:
Education and Academia

NOMINATING COMPANY:
Tandberg

ORGANIZATION:
Arizona Telemedicine Program

PROJECT NAME:
T-Health Institute



Introductory Overview
The Arizona Telemedicine Program was established by the Arizona State Legislature, in 1996, and is currently housed at the Arizona Health Sciences Center along with the College of Medicine, the College of Nursing, the College of Pharmacology, and the College of Public Health, in Tucson, Arizona. The Program operates the Arizona Telemedicine Network, a large state-wide broadband health care telecommunications network, which links 55 independent health care organizations in 71 communities. Telemedicine services are provided in 60 subspecialties of medicine, surgery, psychiatry, radiology, pathology, and others by dozens of service providers. Over 600,000 patients have received telemedicine services over the network. The Arizona Telemedicine Program is known for its innovations in telehealth and its provision of high quality telecommunications services throughout the region.

The Institute for Advanced Telemedicine and Telehealth (i.e. T-Health Institute), a division of the state-wide Arizona Telemedicine Program, has its headquarters in the University of Arizona College of Medicine’s new Phoenix Campus. The T-Health Institute’s T-Health Amphitheater was designed, in part, to accommodate the special audio-visual requirements of its Arizona Interprofessional Learning Center (AILC Program). The T-Health Amphitheater has a highly innovative audio-video system that facilitates the assembly of ad hoc in-the-room electronic interdisciplinary groups. Each group has four to eight participants, who will be displayed in clusters on a 5 foot by 20 foot high resolution video wall at the front of the Amphitheater where the participants are also physically located. This is an example of “in-the-room” video conferencing. This serves our purpose of attempting to improve group dynamics in interprofessional teams through innovative uses of video conferencing. To accomplish this, a sophisticated command and control system manages the video inputs of the individual participant’s head-and-shoulder video images. An audio mixer will manage the separate voice channels of the individual participants and mix them into group voice channels for the use of the group participants. Creation of this facility is intended to directly address the Institute of Medicine's mandate to improve interprofessional training in the United States.

The strong endorsement in the United States, by its prestigeous National Academies Institute of Medicine (IOM), of a interdisciplinary team approach to health care delivery has recently increased the visibility of interprofessional teams. It is encouraging educators to increase their efforts to develop interdisciplinary curriculum and to incorporate interprofessional team training into their school’s curriculum. The National Academies Institute of Medicine (IOM) has a major interest in the topic of quality of health care. Its 2001 Institute of Medicine report “Crossing the Quality Chasm: A New Health System for the 21st Century” identified the magnitude of the health care quality issue in terms of deaths each year in the United States tied to quality of care issues. The report described the IOM’s intent to take measures to improve patient care and safety. In 2003, the IOM published a follow-up report, “Health Professions Education. A Bridge to Quality”. The report noted that “although the academic environment of the various health professions generally are not interdisciplinary, practice environments are increasing so, posing a serious disconnect.” The report proposed that a collaborative approach to education reform be undertaken in order to promote collaboration among clinicians in practice settings. A recommendation in the report was for “…the developing and funding of regional demonstration learning centers, representing partnerships between practice and education. These centers should leverage existing innovative organizations and be state-of-the art training settings focused on teaching and assessing a set of core competencies” identified in the IOM report. The T-Health Institute represnts on of the first such centers.

The Importance of Technology
How did the technology you used contribute to this project and why was it important?
The Arizona Telemedicine Program (ATP) is unique in the United States because it was conceived as a "Network of Networks". As such, ATP has provided the expertise to enable the creation and connective of other state-wide and regional networks within ATP system, including the Arizona State Prisons System; Banner Health Corp; Indian Health Services; Arizoan Behavioral Health Systems and others. The Arizona Telemedicine Program (ATP) is centered around technology.

Without reliable key technologies in place, the program would not exist. Since its inception in 1996, “The ATP has grown from eight sites to 171 sites, in 71 communities and 55 health care organizations,” notes Dr. Weinstein, Director of the Arizona Telemedicine Program. “We have done over 600,000 cases – mostly radiology, but many other specialties as well. It has become a major academic driver for the University; we, and our members, have received over $25 million in external funding, not including a large recent FCC grant.” At the core of the ATP is our ATP-operated telecommunications network which was conceived, built out, and is operated by the ATP's own, university-employed core of engineers. "Large telecommunications companies were disinterested in extending telecommunications to Arizona's vast rural areas when we started in 1996. We took matters into our own hands and built our own virtual utility. This changed the health care delivery system in Arizona in ways that have now benefited hundreds of thousands of patients and thousands of health care professionals and students. Today, a woman on an Indian reservation, in a very rural area, can have her digital mammography reports in an hour. Radiology CT scans are routinely read out immediately for car accident victims, avoiding hundreds of air evaculation of patients to urban medical center. Many lives of traumatic injury patients have been saved", according to Dr. Ronald Weinstein, Co-Founder and Director of the ATP.

The Arizona Telemedicine Program operates a unique, dedicated broadband health care infrastructure, which functions as a telecommunications collaborative providing access to T-1/ATM telecommunications on a private network throughout the state on a cost-sharing basis, and links 171 sites. Using the network, teleconsultations are provided on the Navajo, Hopi and Apache reservations, in the Arizona Department of Corrections, at many rural hospitals, as well as at several community health centers and schools.

“T-Health is a center of innovation,” Dr. Weinstein remarks. “It is a first-of-its-kind facility specifically designed to meet the objectives of the National Institute of Medicine – to address the lack of interdisciplinary health care training using advanced technology in the United States.”

Benefits
Has your project helped those it was designed to help?   Yes

Has your project fundamentally changed how tasks are performed?   Yes

What new advantage or opportunity does your project provide to people?
In addition to the ATP role as a network of networks, and in clinical consultations, our program has made an impact in two other important area (1), education and training, and (2) research in telemedicine technology utilization. We have shown that our transmission of medical, nursing, and pharmacy grand rounds to participants in remote areas of the state is enabling them to modify their practice through new knowledge of emerging medical innovations. Another important advancement is reflected in our technology research in collaboration with Tandberg that has resulted in redesign of certain telemedicine applications to better fit clinical practices.

Although teaching health care students how to function in interdisciplinary teams, in order to prepare them for careers as interdisciplinary team members, may be a desirable objective, it is difficult to do so on a large scale. There are many barriers including: the traditional strict separation of health care professions into discipline-specific tracks; issues in authority management in education institutions; logistical issues since the curriculum of medical schools, nursing schools, pharmacy schools, and others are not coordinated; lack of incentives for most faculty members to work on new health care paradigms; resistance to innovation within the health care professions; and many more. Although the barriers to success in developing programs as envisioned by the IOM are high, successes can be expected if outcome expectations can be carefully delineated at the beginning. On the other hand, we suggest that the rate of progress in this area can be accelerated by leveraging advances in distance learning technology, video conference facility design, and encouraging the involvement of a broad spectrum of stake holders in health care education. Our approach takes so-called “team–based learning” to a different level by masking certain interprofessional barriers by using in-room video conferencing technology. While it might be argued that a limitation of video conferencing is the masking of certain affects and reactions, and that the media creates a somewhat artificial environment, we are attempting to leverage the limitations into a better team learning environment. We will also determine if “electronically” re-shuffling the students from different health care disciplines, into ad hoc work groups to improve the group dynamics.

Our strategy was influenced, in part, by some seemingly provocative observations made by our clinical staff and distance learning staff over the years. They have repeatedly observed that utilizing Tandberg video conferencing creates what appears to be a more neutral environment than in-person meetings for people coming from diverse employment, cultural, ethnic, geographic, and economic backgrounds. It turns out that some people find interacting by video conferencing noticeably less challenging than participating in face-to-face group discussions. A subset of individuals who seem reluctant to exert themselves in group discussions in person will take a more proactive role in video conferences. Also, some individuals who are reluctant to challenge authority in-person seem more willing to do so at video conferences. These observations, and others along the same lines, led us to raise several questions:

• Could in-the-room video conferencing technology be used to minimize the barriers imposed by the discipline-specific barriers within groups?

• Could in-the-room video conferencing be used to improve group dynamics and the quality, and student and faculty satisfaction with interprofessional team training?

• Can electronically embedding “stakeholders” catalyze the group interactions and favorably affect the outcome of interprofessional training sessions?

The design of the T-Health amphitheater will enable us to explore these questions and many others in a systematic way.



If possible, include an example of how the project has benefited a specific individual, enterprise or organization. Please include personal quotes from individuals who have directly benefited from your work.
There have been numerous testimonials to the impact of the ATP and T-Health on specific individuals, enterprises and organizations. Some quotable samples are as follows:

“T-Health’s purpose is to innovate and develop novel distance learning and health care delivery to revolutionize how people are educated and how they receive health care, “ Weinstein, Director of the ATP said. “T-Health will leverage what we’ve learned about health care education from the telemedicine program and address the issue of how technology can change the way we educate health care professionals.”

Telemedicine and telepresence for trauma and emergency care management, 2007.
Dr. Rifat Latifi, a trauma surgeon at University Medical Center in Tucson, oversees telepresence services at distant rural Arizona hospitals. For examplel, after a patient, at a rural hospital over 126 miles away, was placed on the helicopter for a ride, the joyful, but exhausted and pale-looking physician at one of the rural hospital turned on to the video camera, her face filing the screen and said, “Thank you (to Dr. Latifi on the other end) so much for being with us here today (by telepresence). Without you, this child would have died.” “Telemedicine will become a major tool in trauma care and trauma education. Trauma resuscitation can be performed successfully and safely using telemedicine principles, when guided by and under direct supervision of a trauma surgeon,” states Dr. Latifi, an international expert on telemedicine and telehealth applications. Many childrens and adults lives have been saved.

T-Health and the ATP have created the first same-day breast care service. This bundles telemedicine-enabled digital mammography, telepathology and teleoncology. Women can come in for a digital mammography, have a core biopsy with immediate laboratory processing and readouts by a pathologist and, if indicated, then immediately meet with an oncologist or surgeon for clinical planning. Instead of taking 21 to 30 day, as is standard practice, this all takes place in a single day. Carol Peaks, a patient who was the first user of the service said, “I was so happy (when my biopsy was benign and I got my results immediately ). I believe this program will be a benefit to many people who are unable to travel to see a specialist or who would feel better with results in a couple of hours. I found the service to be excellent in so many ways”.

Tucson Citizen February 15, 2008
“I think that the most important aspect (of T-Health based medical services) is delivering high-quality care with compassion,” Sisley said. Dr. Sue Sisley a psychiatrist based in Phoenix, Arizona “Feedback from patients has been overall very good,” she adds.

Dr. James Baird, Arizona Department of Corrections' medical director for health care services was quoted as saying, “This is a perfect example of a program that allows us to keep the public safe,” and “there is no transport with a telemedicine appointment, so there is no chance of escape or mischief by the inmates.”

Dr. Herb Schwager a Willow, Alaska-based clinical telepsyhcologist, who provides sevices into rural Arizona over the network from his home Alaska said, “This could not happen without telemedicine,” Schwager said. “I can see everything that the on-site physician sees.”

Arizona Telemedicine Program Shares $15M FCC Grant UA News December 12, 2007
“This upgrade in Arizona will enable us to support a number of next-generation telehealth applications,” said Dr. Weinstein. “We anticipate that access to secure high-speed communications via new national network backbones will be important for telemedicine applications that are under development, such as three-dimensional imaging, and will catalze a new round of innovation in the telehealth

Originality
Is it the first, the only, the best or the most effective application of its kind?   All of the above

What are the exceptional aspects of your project?
The ATP is known for innovations in telehealth and its provision of high quality telecommunications services throughout the region. The University of Arizona College of Medicine was established in Tucson, Arizona, in 1967. In 2004, the Arizona Board of Regents decided to create a second Univesity of Arizona Campus Arizona, in Phoenix, Arizona. The ATP was named one of the five enabling organizations for the new campus in Phoenix. Twenty five million dollars was raised to rennovate three historic high school buildings to house the first class of 24 medical students. The ATP designed a multi-functional conferencing center in the Auditorium Building. This amazing Auditorium Building now includes a 250 seat auditorium with a 12 foot by 32 foot video screen, two multi-media class rooms, and the T-Health Institutes suite consisting of a telemedicine training facility, telemedicine services clinic, and the state-of-the art T-Health Amplitheater.

The T-Health Amphitheater is a unique arena designed for a new level of video presentation flexibility including integration of voice, video and data. An area of the theater is partitioned for confidential telemedicine consultations utilizing a Tandberg 1500 video conferencing system. A key component of the theater is a 2x6 video wall consisting of 12 50” Toshiba P503DL DLP Datawall RPU Video Cubes each capable of 1024x768 (XGA) Resolution resulting in a combined resolution for the entire wall of 6144x1536 pixels. The video wall is controlled by a Jupiter Fusion 960 Display Wall Processor utilizing dual Intel Xeon processors. The Fusion 960 will allow the wall to display fully moveable and scalable images from multiple PC, video and network sources. Four additional 45” LCD Displays on the rear wall of the theater will be utilized to provide the instructor with views of remote computer and video displays. An adjacent elevated dedicated control room houses all room audio and video switching equipment and Tandberg CODECs to connect the theater to other videoconferencing and telemedicine locations worldwide. Seventeen student desks are embedded into three long benches. Each desk will be equipped with a laptop “garage” that can be activated by the instructor and individual video cameras and microphones allowing each participant to be an audiovisual role-player on the video wall. Theater style lighting fixtures are ceiling mounted to assure adequate, fully controllable lighting on all room participants. A free standing Wharton Lectern with a Crestron control panel will be utilized by session facilitators to control video wall scenarios and access the PCs in the participants laptop garages. The T-Health Amphitheater will have a one-of-a-kind audio-video system that facilitates the production of ad hoc in-the-room electronic interdisciplinary groups. The T-Health Amphitheater seats up to 17 participants at desks, with additional temporary seating in the back of the room. Each of the participants will have individual headphones and microphones. The plan is to display each of their individual video images, usually in group-specific clusters, on the video wall at the front of the room. Personal voice channels will be clustered according to the placement of the individual images in specific groups on the video wall. For purposes of interprofessional health care training, it will be possible to display ad hoc “electronic groups” on the video wall. This is an example of “in-the-room” video conferencing. This serves T-Health’s purpose of attempting to improve group dynamics in interprofessional teams through innovative uses of in-the-room video conferencing. An audio mixer will manage the separate audio channels of the individual participants and mix them into group-specific channels for the exclusive use of the group participants. The facility is currently used for multi-media video conferencing and will be fully functional by Fall, 2008.

Difficulty
What were the most important obstacles that had to be overcome in order for your work to be successful? Technical problems? Resources? Expertise? Organizational problems?
Anytime a group undertakes creating a "first-of-a-kind" video conferencing facility, it might as well be expected that there will be technical problems, resource issues, expertise issues, and organizational problems. The T-Health Institute is no exception and has been especially challenging since the T-Health Institute is a semi-autonomous entity embedded in an operational College of Medicine Campus. We are successfully meeting all of these challenges yet it requires a great deal of effort. The stakes are high since lives are being lost in the United States because of the lack of health care professionals working together.

We have a number of lessons learned from the project. First, if you are starting at ground zero, everything is going to take longer and cost more than you expect. The time and distance element of creating a first rate telehealth facility 130 miles away can be daunting but manageable. The mandatory utilization of the architects, audiovisual consultants, and contractors chosen by the University of Arizona for the entire project had both a positive impact on the project as well as some downside impacts. Utilizing a first rate team resulted in a world-class facility design but the need to contribute significant project funds to the renovation process resulted in a shortage of funds to complete Phase One of the project. The audiovisual consulting company, specified equipment needs for the equipment in the Amphitheater. It turned out that there is a great deal of underlying hardware and software infrastructure in this system as currently installed that is only accessible and configurable by trained technicians using networked computer access. The designers assumed that this was to be a system operated by laypeople using touch screen presets programmed by their technicians and as such, installed sub-systems that have little to no direct user interface. In order to take control of this system, there will have to be a variety of training for ATP staff so that they can program and operate the various sub-systems with minimal intervention by the vendor’s technicians. These systems include audio, video wall and system top-level management. The lighting designed by the contractor initially lacked the ability to forge dynamic on-screen imagery commensurate with a high-profile project but this is being remedied by a re-design of the lighting. The initial system is workable but the re-engineered system will be much better. The audio vendor indicated that there was no problem with the audio because he was able to communicate with the system just fine. There was a real problem, of course, because it turned out that the ATP staff could not communicate with that system – there was no user interface aside from a virtual interface of which ATP has no working knowledge or access. This has been remedied as well.

The design, product and installation teams were different and had varying ideas of how the facility should work. It would have been advantageous to have these vendors communicate better or use one vendor for the entire project. Other obstacles included major problems with environment control in this century old building. Thus, development of a first-of-a-kind facility is very demanding on staff time and integrity. On the other hand, the outcome can be revolutionary. Another important element in the successful equipping of this facility for multi-site video conferencing, multi-media presentations, participant feedback and testing, and video production was the development of a significant industry partnership with Tandberg, a world leader in videoconferencing technologies and long time provider of equipment for the Arizona
Often the most innovative projects encounter the greatest resistance when they are originally proposed. If you had to fight for approval or funding, please provide a summary of the objections you faced and how you overcame them.
The greatest resistance actually occurred before the ATP was invited to create the Institute for Advanced Telemedicine and Telehealth (T-Health Institute) in Phoenix. Creation of this Phoenix campus, under the auspices of the University of Arizona rather than Arizona State University, was controversial for decades. For background, Arizona is the sixth largest state in the United States. Its only allopathic medical school was founded in 1967 and is headquartered at the University of Arizona campus in Tucson, Arizona. The largest city is the state’s capital, Phoenix, located 100 miles northwest of Tucson. In 2004, the Arizona Board of Regents, the governing body for Arizona’s three state universities, made a decision to establish a branch campus of the University of Arizona College of Medicine in Phoenix. Three unoccupied historic high school buildings, originally built in 1911 and 1912 and totaling 85,000 square feet, would be renovated to house its first class of 24 medical students by the summer of 2007. As part of its initial decision to move ahead with the development of a University of Arizona College of Medicine Phoenix Campus, the Arizona Board of Regents named the Arizona Telemedicine Program as one of five enabling resources in its “Memo of Understanding” that created the University of Arizona College of Medicine Phoenix Campus. The four other entities were The University of Arizona, Arizona State University, Northern Arizona University, and the Translational Genomics Institute. The issue was finally resolved by the Arizona Board of Regents. Today, the campus is officially The University of Arizona in Partnership with Arizona State University, College of Medicine. The President of the UofA invited the ATP to submit a proposal for a federal earmark to fund construction of T-Health Institute on the new College of Medicine Campus in Phoenix. Funding of the earmark was successful.

Success
Has your project achieved or exceeded its goals?   Achieved

Is it fully operational?   No

How do you see your project's innovation benefiting other applications, organizations, or global communities?
Our project's success will affect many other applications. The concept of in-the-room video conferencing is new and should prove to be revolutionary in terms of improving group dynamics within heterogeneous user groups. This has been facilitated by the Tandberg 6000 and the extremely mobile T150. Many organizations, even within individual fields such as health care, or involved with a single disease, such as diabetes or cancer, are relatively isolated from one another. For example, in Arizona, there are 403 different organizations that are concerned with diabetes. We established an Arizona Diabetes Center of Excellence (the ADVICE program) and found that video conferencing helps with the diffusion of information among different organizations concerned with the same basic problems. One objective was to create and evaluate innovative distance learning programs on diabetes for patients, families, children, community-based allied health professionals, and physicians in rural areas, thereby creating a community-based infrastructure for diabetes health education. One of these projects was to develop, provide and evaluate annual community health center-based telehealth diabetes learning activities for K-12 student groups and their families that are age-appropriate and culturally sensitive. The primary lesson learned in regard to this objective was the unique motivational value of engaging middle school students in cross cultural exercises to promote a better understanding of diabetes. This was discovered in year one with the science project exercise that allowed Hispanic students in Nogales, Arizona to share their findings about diabetes impact on their families and themselves as individuals with Navajo students in Tuba City, Arizona. The students enjoyed discovering differences in each other’s cultures. In years two and three these cultural differences were further explored by having student groups in Nogales and Tuba City produce and perform the play developed by Tucson Arizona’s Senior Girl Scout Troop 509 called “The Evil Diana Betes vs. Sir Insulin Monk”. Students in each location were able to creatively bring lifestyle elements from their unique cultures into the play as teaching points about diabetes. In year three it was hoped that email projects between the students could be utilized as a cross-cultural project. However, problems with computer access for email use and concerns about inappropriate email use complicated this approach. As a less problematic alternative, an on-line discussion group was formed which utilized web shareware.

It is particularly important to point out that ATP was among the first telemedicine programs in the U.S. to reach out to tribal populations and introduce them to the benefits of telemedicine technology. A decade ago we worked closely with members of the Hopi Tribe, Whiteriver Apache Tribe, and the Navajo Nation to bring the technology to their doorsteps, and to do so in a culturally sensitive manner. For example, when our telemedicine equipment was initially launched at the IHS Hospital in Whiteriver, a medicine man was on hand to give a traditional blessing to ensure tribal members acceptance of the new concept of receiving health care.

We will now extend these important types of educational activities using the T-Health Institutes Amphitheater which will enable us to bring many participants, from multi-reservations, using small Tandberg T-150 desktop video conferencing units onto a large Jupiter command-and-control video wall and permit them to interact in "electronic groups" together with off-site as well as with individuals seated in the T-Health Amphitheater. This should further improve intergroup communications and greatly expand the numbers of user groups of the facility. There are numerous medical and non-medical applications that will benefit from our novel and unique approach to in-house and multi-site video conferencing.





How quickly has your targeted audience of users embraced your innovation? Or, how rapidly do you predict they will?
The T-Health Institute and, its shared video conferencing facilities in Phoenix, has been an immediate success. The Auditorium Building has been a magnet for the Phoenix community and state agencies. For example, this past year Governor Janet Napolitano gave her "State-of-the-State" speech in the auditorium. Likewise, the Phoenix Mayor gave his "State-of-the City" speech there. Over 40 different public and private organizations have used the Phoenix Campus Auditorium since the Spring of 2007. Organizations as diverse as the Epilepsy Foundation, the Arizona Department of Health Services, the IHS, the Arizona Bioindustry organization, Tandberg, and the Arizona HealthCare Executives organization have used the facility for their meetings. The multi-media classroom are heavily used by both the community and for class room acitivities of the on-campus College of Medicine students. T-Health has sponsored many video-enabled events in the video conferencing rooms, including regional meetings of the Southwest Indian Health Service medical directors and leaders of the national Pathways Program, which is bringing innovative distance learning experiences to schools, hospitals and community health centers. The T-Health Institute's facilities are used for many in-house programs including telemedicine training programs, community-based outreach programs, and international programs. Currently,the T-Health Institute and the ATP have major education and telehealth service programs based in the Balkans and in Latin America. These programs also extend into China. In summary, the T-Health Institute and its shared Auditorium facilities have rapidly emerged as an important, heavily used multi-media center that is having major impact locally, regionally, nationally, and internationally. The T-Health Institute will have a very significant role in addressing the Institute of Medicines concerns over interprofessional training in the future as well.
Digital/Visual Materials
The Program welcomes nominees to submit digital and visual images with their Case Study. We are currently only accepting .gif, .jpg and .xls files that are 1MB or smaller. The submission of these materials is not required; however, please note that a maximum of three files will be accepted per nominee. These files will be added to the end of your Case Study and will be labeled as "Appendix 1", "Appendix 2" or "Appendix 3." Finally, feel free to reference these images in the text of your Case Study by specifically referring to them as "Appendix 1", "Appendix 2" or "Appendix 3."

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