Current Principles and Practices ofTeleinedicine and e-Health
R. Latifi (Ed.)
lOS Press, 2008
© 2008 R. LatW. All rights reserved.
Integrating Telemedicine and Telehealth:
Putting ItAll Together
Ronald S. WEiNSTEIN,MDa,l~,Ana Maria LOPEZ, MD, MPH~,
Elizabeth A. KRUPINSKJ, PhDa,,1Sandra 3. BE1NAR”, Michael HOLCOMBa,d
Richard A. McNEELY~, Rifat LATIFI, MD,FACSa,f
and Gail BARKER, MBA,~
gUniversity ofArizona College ofMedicine-Tucson Campus, Department ofFinancial
Affairs, University ofArizona College ofMedicine-Phoenix Campus
Abstract. Telemedicine and telehealth programs are inherently complex compared
with their traditional on-site health care delivery counterparts. Relatively few or
ganizations have developed sustainable, multi-specialty telemedicine pro~rams, al
though single service programs, such as teleradiology and telepsychiatiy j~ograms,
are common. A number of factors are barriers to the development of sustainable
telemedicine and telehealth programs. First, starting programs is often,challenging
since relatively few organizations have, in house, a critical mass of individuals
with the skill sets required to organize and manage a telemedicine program. There
fore, it is necessary to “boot strap” many of the start-up activities using available
personnel. Another challenge is to assemble a management team that has time to
champion telemedicine and telehealth while dealing with the broad range ofissues
that often confront telemedicine programs. Telemedicine programs housed within
a single health care delivery system have advantages over programs that serve as
umbrella telehealth organizations for multiple health care systems. Planning a
telemedicine program can involve developing a shared vision among the partici
pants, including the parent organizations, management, customers and the public.
Developing shared visions can be a time-consuming, iterative process. Part of
planning includes having the partnering organizations and their management teams
reach a consensus on the initial program goals, priorities, strategie~, and imple
mentation plans. Staffmg requirements of telemedicine and telehealth programs
may be met by sharing existent resources, hiring additional personnel, or outsourc
ing activities. Business models, such as the Application Service Provider (ASP)
model used by the Arizona Telemedicine Program, are designed to provide staff
ing flexibility by offering a combination of in-house and out-sourced services, de
pending on the needs of the individual participating health care organizations.
Telemedicine programs should perform ongoing assessments of activities, ranging
from service usage to quality ofservice assessments, to ongoing analyses offinan
cial performance. The financial assessments should include evaluations of costs
and benefits, coding issues, reimbursement, account receivables, bad debt and
network utilization. Long-range strategic planning for a telemedicine and tele
health program should be carried out on an on-going basis and should include the
program’s governing board. This planning process should include goal setting and
the periodic updating ofthe program’s vision and mission statements. There can be
additional special issues for multi-organization telemedicine and telehealth pro-
R.S. Weinstein et at. /Integrating Telemedicine and Telehealth: Putting ItAll Together
grams. For example, authority management can require the use of innovative ap
proaches tailored to the realities ofthe organizational structures ofthe participating
members. Inter-institutional relations may introduce additional issues when com
peting health care organizations are utilizing shared resources. Branding issues are
preferably addressed during the initial planning of a multi-organizational telemedi
cine and telehealth program. Ideally, public policy regarding telemedicine and
telehealth within a service region will complement the objectives of telemedicine
and telehealth programs within that service area.
Keywords. Integrating Telemedicine and Telehealth, Business models for tele
medicine, evaluation of costs and benefits, coding issues, reimbursement, planning
of a multi-organizational telemedicine and telehealth program, public policy
In 1996, the Arizona State Legislature gave the state’s only medical school, the Univer
sity ofArizona College ofMedicine headquartered in Tucson, Arizona, the opportunity
to develop a statewide telemethcine program [1 61. A legislative proponent of tele
medicine, State Representative Robert “Bob” Burns (R-Glendale, now a State Senator)
spearheaded the legislative initiative to create an eight-site pilot telemedicine pro
gram . Over a decade later, he remains the Arizona Telemedicine Program’s strong
est proponent. By coincidence, an early adopter of telepathology, the first author on
this chapter (RSW), was the Pathology Department Head at the University of Arizona
at the time and was willing to serve as the Founding Director of the Arizona Telemedi
cine Program on a part time basis. Dr. Weinstein had trained in pathology at the Mas.~
sachusetts General Hospital (MGH) in Boston, Massachusetts in the 1960s when the
world’s first multi-specialty telemedicine program was established at that institution.
Although he was not personally involved in the MGH program he was well aware ofit,
since it was widely publicized in the press. He subsequently invented robotic
telepathology in 1986, for which he was granted U.S. patents, and published many pa
pers and books on telepathology [7 12]. He was on the international lecture circuit as a
speaker on telemedicine and telepathology before the Arizona State Legislature devel
oped its interest in supporting a pilot project . For over a decade, he has had a dual
role as Head of Pathology and Director of the Arizona Telemedicine Program . To
day, Senator Bums and Dr. Weinstein continue to work closely together on the devel
opment of statewide and regional telehealth programs (Fig. 1).
The initial collaboration of a key legislator and a medical school department head
with a special interest in telemedicine led to the immediate development and imple
mentation of statewide telemedicine and telehealth public policies . Since then, these
public policies have served as the framework for developing many additional telemedi
cine and telehealth initiatives in Arizona. Being able to start with a clean slate and ad
dress a multiplicity of program requirements, such as that of creating a new statewide
broad band telecommunications infrastructure, allowed the Arizona Telemedicine Pro
gram to develop an unusually inclusive multi-organizational program from the bottom
up, while documenting lessons learned as part ofthe process . These lessons learned
form the basis for this chapter. Although many of these lessons grew out of this spe
cific program, they may be broadly applicable to other programs as well.
R.S. Weinstein et al. llntegrating Telemedicine and Telehealth: Putting It All Together
Figure 1. Founders of the Arizona Telemedicine Program at their initial orga
University ofArizona College ofMedicine, Tucson, Arizona, in June 1996. The phdt~graph was taken in an
open area outside of the Arizona Health Science Center Library. Left to right: Richard A. McNeely, Found
ing Co-Director of the Arizona Telemedicine Program and Director of Biomedical Communications at the
Arizona Health Sciences Center; Ronald S. Weinstein, M.D., Founding Director ofthe Arizona Teleniedicine
and Professor and Head of the Department of Pathology, University of Arizona College of Medicine; State
Representative Lou-Aim Preble, from Tucson, an early advocate oftelemedicine; State Representative Robert
“Bob” Bums, (now Senator Bums) who started the statewide telemedicine initiative in Arizona and has
chaired its governing body, the Arizona Telemedicine Council, since the beginning; Rachael Anderson, an
Associate Director of the Arizona Telemedicine Program and Director of the Arizona Health Science Center
Library; and John 3. Lee (deceased), Deputy Budget Director at the Joint Legislative Budget Committee of
the Arizona State Legislature. Mr. Lee played a major role in creating the governance structure for the Ari
zona Telemedicine Program and in helping the Arizona State Legislature and the University ofArizona Col
lege ofMedicine to develop a shared vision for this statewide telemedicine and telehealth enterprise. A statue
ofHippocrates (background) adds a sense ofhistory to the event.
meeting, held at the
1. Current Developments: Evidence-Based Practice
Good telehealth public policy is obvious when you see it. At the time of the organiza
lion of the Arizona Telemedicine Program, eight public policies were proposed by
Dr. Weinstein as components of his “start up package.” These were immediately en
dorsed by influential leaders in the Arizona State Legislature . The policies were
authored as a package of public policies and presented as a unit. The authoring of the
policies was completed in four hours by Dr. Weinstein. Endorsement by the Co-Chairs
of the Joint Legislative Budget Committee of the Arizona State Legislature took place
within days. Since then, these telemedicine policies have provided the framework for
the development of many of the telemedicine and telehealth activities in Arizona. It is
doubtful that these policies would have been accepted on a piecemeal basis since they
make the best sense when viewed in their entirety. These policies have been described
elsewhere  and are summarized as follows.
R.S. Weinstein et al. /Integrating Telemedicine and Telehealth: Putting It All Together
• To have, as a goal, the creation of a single statewide multi-service telemedi
To establish a program governance framework with an overarching authority
structure to support the unique missions of a statewide telemedicine organiza
To operate the program as a virtual organization that would be inclusive and
create incentives for all health care organizations to participate in a statewide
single telemedicine program.
To provide access to the program’s telecommunications infrastructure for all
legitimate health care organizations in the state.
To encourage the development ofinteroperability of all telemedicine facilities
To develop an open staff model for participation of telephysicians as service
providers for multiple health care organizations.
To promote best practice guidelines that are evidence-based and supported by
To have the state legislature encourage all state agencies, including the Ari
zona Department of Corrections and the Arizona Department of Health Ser
vices, to participate in the program .
The governance issue was addressed by the creation of the Arizona Telemedicine
Council, a so-called non-statutory overarching authority. This Council has approxi
mately 25 members from government, both the public and private sectors ofthe health
care industry, and community members. It has been chaired by Mr. Burns since its
creation 11 years ago. The Council meets quarterly for a two hour luncheon meeting at
the State Capital Campus in Phoenix. Mr. Burns, the Council Chair, and Dr. Weinstein,
the Director, have attended all 43 meetings to date.
At the first meeting of the Arizona Telemedicine Council in 1996, the Director
proposed broadening the scope ofthe Arizona Telemedicine Program as it was outlined
initially by the State Legislature in its enabling legislation. The Director wanted to de
velop a “comprehensive telemedicine program” (Fig. 2). He thought that this was es
sential in order to achieve sustainability of the program. Also, he regarded many of the
then available applications of telemedicine as unproven health care delivery systems at
the time. Implementation of the statewide program would take place along with on
going assessments of the candidate telemedicine technologies. His proposal was for a
telemedicine program with five components: 1- telemedicine services; 2- a technology
assessment division (i.e. clinical research division); 3- on-going telemedicine training
programs; 4- distance education; and 5- the development of a telemedicine infrastruc
ture, including a shared telecommunications network arid standardized telemedicine
clinical facilities throughout Arizona (Fig. 2). Establishment of interoperable telemedi
cine clinics in independent health care facilities across the state was regarded as key to
success. Strong branding of the Arizona Telemedicine Program was also thought to be
important. Initially, legislative leaders had concerns about encouraging clinical re
search within the program due to their apprehension that this might distract academic
physicians from the telemedicine program’s primary mission of patient care. This con
cern dissipated as the program’s staff competed successfully for federal grants and
proved to state leaders that it was fully committed to making telemedicine services ef
fective throughout the state.
Today, the Arizona Telemedicine Program serves as an umbrella organization for
55 independent health care organizations located in communities throughout Arizona,
R.S. Weinstein et al. /Integrating Telemedicine and Telehealth: Putting It All Together
Figure 2. The components ofthe comprehensive telemedicine program developed by the Arizona Telemedi
cine Program. The program integrates telemedicine and telehealth services with clinical research and distance
learning activities. In addition, the Arizona Program operates the broad band Arizona Telemedicine Network.
Introduced at the second meeting ofthe Arizona Telemedicine Council in the Fall of 1996.
adjacent states, and in other countries. Health care facilities in both urban and rural
communities, on Native American reservations (i.e., the Navajo, Hopi, and Apache
Nations, among others), in all of Arizona’s 10 state prisons, and in community health
centers and schools are members of the Arizona Telemedicine Program. The Arizona
Telemedicine Program owns (Arizona Board of Regents is the actual owner) and oper
ates a private health care broad band telecommunications network, the Arizona Tele
medicine Network, that links 171 sites in 71 communities ranging in size from
280 people to 1.9 million people (Fig. 3). It operates an Application Service Provider
(ASP) business which offers a wide range of services and facilities to the Arizona
Telemedicine Program ASP members . This ASP business is critical to the sustain-
ability ofthe program.
Telehealth services are offered over the Arizona Telemedicine Network in over
60 subspecialties of medicine and nursing. For example, twenty-eight hospitals in the
region receive teleradiology services 24/7 provided by university-based physicians in
Tucson. Over 2500 patients have received teledermatology diagnoses by store-and-
forward teledermatology. Telepathology services are delivered to rural communities
either by robotic telepathology, in some communities, or virtual slide telepathology,
(i.e. whole slide digitization), the most advanced technology in the field, in other com
inunities. It is estimated that 80 per cent of the specialty consultations for the
36,000 prisoners housed by the Arizona Department of Corrections are delivered di
rectly into the prisons by telemedicine, thus avoiding tens of thousands of miles of
travel by guarded prisoners every year. Prisoner and service provider satisfaction with
the correctional telemedicine services in Arizona is high. There are also several affili
ated telepsychiatry networks in Arizona. In total, there have been over 40,000 telepsy
chiatry patient sessions to date. Tallying all specialties combined, 500,000 Arizona
patients have received telemedicine services since the inception of the program. Many
R.S. Weinstein et al. lintegrating Telemedicine and Telehealth: Putting It All Together
ARIZONA TELEMEDICINE NETWORK
eyIze~Ia t.IembdICIIt~ Pro~r~ SIL.
A~ani e.p~.tm,nIci C ,r.ctlmc crAlfllJ~t,
•Plma~oeMy IncH U1IDHII H•IIUI
~ HdU~HQ~HI SC,
Ncv~JnAr#c Indb~. H.~Id,~
-—--- Pending or Ptanned circuit
— DSI (Ti) sIngle or nrvltipln
Figure 3. Arizona Telemedicine Network is staffed by the Arizona Telemedicine Program engineers. The
network equipment is owned by the Arizona Telemedicine Program.
of these patients are in rural areas of the state. However, the numbers of urban tele
medicine and telehealth cases are on the rise in Arizona .
With regard to technology transfer activities, funding for clinical research and the
development of innovative telehealth services has exceeded expectations. The Arizona
Telemedicine Program and its affiliates have been awarded 61 extramural grants total
ing over $23,000,000. There are two telemedicine spin off companies from the Univer
sity ofArizona and the Arizona Telemedicine Program, DMetrix, Inc., and UltraClinics,
Inc. [13—18]. The return-on-investment for the state has been very good at over
2.3 times the original investment. To date, the Arizona Telemedicine Program and its
staff have won nine national and international awards, including awards as a top tele
medicine program, for distance education over a telernedicine network, and for clinical
research, including technology assessment .
R.S. Weinstein eta!. /Integrating Tele,nedicine and Telehealth: Putting It All Together 29
Table 1. Components of a Telemedicine and Telehealth Program
Facilities Design and Implementation
Health Care Services
Legal and Regulatory
Financial and Business
Marketing and Public Affairs
Critical component ofearly stage planning
Facility interoperability is a major goal
Challenge especially in multi-organization programs
Impacted by organizational structures
Establish potentially high volume services first
Services including maintenance must be ofhigh quality
Largely a local matter except on network issues
Must be abreast oflatest developments
Policy can drive reimbursement
Branding requires creativity and strong leadership
Substantive achievements make good news articles
Government can be a natural partner for regional telemedicine
and telehealth programs
2. Barriers and Issues at Hand
For many health care organizations with an interest in developing a, telemedicine pro
gram, a critical question is ‘where to start9” How does an organization start a telemedi
cine and telehealth program in the absence of any local telehealffiactiyitics? Is the cur
rent health care environment likely to be receptive to innovative hëàlth care delivery
models? [19 26] Arizona was faced with this challenge a decadç ago~
To help independent health care orgamzations address this challenge, the Arizona
Telemedicine Program sponsors regularly scheduled mtroductory courses on telemedi
cine, held at its headquarters at the Anzona Health Sciences Center campus m Tucson
Those courses have been popular and well attended for years. There are one arid two
day versions of the courses. These provide an overview oftelemediciné dud tclehealth,
discuss strategies and road maps for starting programs, atid provide a limited amount of
hands-on experience. The courses emphasize that telemedicine services require many
of the same components that would be needed to start other multi-specialty health care
services. The process of developing these components begins with strategic planning
Typically, only larger health care organizations have all of the core competencies
needed to establish a successful telemedicine and telehealth program, yet the greatest
need for access to telehealth services are often at smaller health care àrganizátions. The
Arizona Telemedicine Program’s ASP business model was designed to provide a
mechanism for its member organizations to obtain otherwise dif~hci.ilt to obtain services
through in-sourcing directly from the Arizona Telemedicine Program . The ease
with which this can be arranged and the cost of the low annual membership fee has
enabled dozens of independent health care organizations to get involved in telemedi
cine and telehealth with relatively little effort and without significantly increasing the
numbers of IT or financial personnel at their organizations. The Arizona Telemedicine
Program also serves an important advocacy role for telemedicine and telehealth at Ari
zona state agencies, such as the state Medicaid program. It is an effective neutral broker
for members interested in participating in a wide range of extramurally funded pro
R.S. Weinstein et al. lintegrating Telemedicine and Telehealth: Putting It All Together
Another challenge for new programs is recruiting a permanent director. Since
telemedicine and telehealth are relatively new, the pool of qualified candidates avail
able to direct new telemedicine programs is limited .
3. Suggested Solutions to Overcome Barriers
For many rural hospitals interested in joining regional telemedicine and telehealth pro
grams, personnel with experience in a number of critical areas could be lacking. The
Arizona Telemedicine Program’s ASP business model acconunodates many of those
needs by providing a menu of these services from which member organizations can
select the specific services they need [5,19]. Telemedicine and telehealth offerings
range from turn-key solutions to simple program connections to other fully developed
sites on the Arizona Telemedicine Network for access to Arizona Telemedicine Pro
Starting a telemedicine and telehealth program in a health care organization with
little prior experience with the concepts and technologies of telemedicine is challeng
ing [23,24]. Nevertheless the future level of success of a new telemedicine and tele
health program can be influenced by the clarity and accuracy of the early vision for the
program. The challenge is to align the program’s vision (i.e., determined locally) with
the vision of the program director, especially when that individual is an outside recruit.
Simultaneously developing a vision statement and recruiting a program director re
quires skillful management ofthe start-up processes by the program initiators. It can be
beneficial to insert highly respected community leaders into this process early on, in
order to provide a strong guiding hand for the process.
We recommend that the process of starting a telemedicine and telehealth program,
or adding an additional conmiunity to an established regional program, start with the
naming of a local Planning Group and the selection of an official facilitator. Often, a
highly respected member ofthe community, such as a former mayor, a respected busi
ness leader, or a member of the hospital’s board can fill this role. The facilitator will
then chair the ad-hoc group that will take on the task of drafting an initial list of out
come expectations for the new program. A telemedicine and telehealth consultant,
preferably an individual with personal prior experience managing a telemedicine and
telehealth program, can be invaluable in assisting the facilitator in establishing goals
and outcome expectations. This consultant, or a separate search finn, can be given the
assignment ofrecruiting a permanent program director. The consultant then works with
the planning group on developing the initial business plan for the new enterprise
The selection of a qualified program director can be critical to the eventual success
and sustainability of a telemedicine and telehealth program. In order to be successful,
telemedicine and telehealth program directors need a broad range of skill sets. In addi
tion, they frequently assume an additional role as spokesperson due to the inherently
public nature of multi-organization telemedicine and telehealth programs. Multi
specialty telemedicine and telehealth programs have a public face and their communi
ties will have an appetite for updates. The telemedicine program director may also be
come a local spokesperson for health care innovation in general, as well as the local
expert on health care access disparities.
R.S. Weinstein et al. llntegrating Telemedicine and Telehealth: Putting ItAll Together
Planning Telemedicine Programs
Figure 4. A strategy the Arizona Telemedicine Program developed to help member sites recruit a director or
medical director for their telemedicine and telehealth program.
A challenge may be to gain adequate community support for cstablishing a com
munity-based telemedicine and telehealth program. Establishing çnthusiastic support
can help the program director recruitment process. The lack of prior. familiarity with
telemedicine and telehealth in communities without access to such services can become
its major barrier to acceptance. It is helpful to develop public support for welcoming
telemedicine and telehealth services into a community. At a later stage of implementa
tion, community support can be used to influence reimbursement policies of insurers,
to give patients complete confidence in the services, and to provide opportunities to
highlight the advantages of in-sourcing subspecialty health carç servides into geo
graphically isolated communities as opposed to having people travel great distances for
subspecialty medical services.
There are a number of other reasons for having communities enthusiastically sup
port local telemedicine and telehealth programs. Distance learning, at many levels of
education, can be carried out over the telemedicine program’s network. Programs de
signed to interest local students in health care careers can be impleme.ntc4. The spon
soring institution can also be proactive in educating community.leaders ab9ut telemedi
cine. A community intem program can bring health care indusiry leaders from many
organizations, business leaders, and government leaders to the program for a two-day
immersion experience in medical center activities, including telemedicine. Also, a
telemedicine program should consider sponsoring one and two day introductory
courses on telemedicine. The Arizona Telemedicine Program has done this for years
and has had over 600 graduates from over 50 independent health care organizations and
agencies in its region. Attendees represent a broad-range of constituents ranging from
patient case managers, to chieffinancial officers, to community leaders.
The Arizona Telemedicine Program has developed a process for initiating a tele
medicine program. Many, but not all, elements have been used in Arizona.
In Phase 1, a preliminary list of telehealth services is generated. By the end of the
Facilitator Phase, a tentative vision for the program will have emerged. This helps
guide the Planning Group to an outside consultant appropriate to the type and scope of
the telehealth program envisioned locally. It also builds in a mechanism for early real
ity testing by the program’s early advocates and invites the making of a crucial “go-no
R.S. Weinstein et al. IIntegrating Teleniedicine and Telehealth: Putting It All Thgether
Table 2. Phases in a Telehealth Program Start-up
Drafts the initial vision and outcome expectations documents for the
telemedicine and telehealth program, aimed at providing the outside
consultant with local information and perspective (Fig. 3).
Helps design the telemedicine and telehealth program; lists and
prioritizes key tasks including the recruitment of a permanent
Recruitment ofthe permanent director for the program. The director
typically becomes a “champion” for the program, although this role
should be shared with key government officials and high profile
community leaders. There are many other possible candidates for
the “champion” role.
Planning & Implementation
Move from concept through start-up and ramp-up ofthe new
telemedicine and telehealth organization.
go” decision by the leadership group. It is important to understand that a “one-size-fits
all” approach does not work for all sites. Only those telemedicine or telehealth services
identified as necessary should be initially implemented. An expansion of services can
be added as needs arise.
In Phase 2, the consultant works with the Planning Group and the Facilitator on
designing some of the specifications of the program and generating a sample list of
tasks for the “soon to be” recruited director.
Phase 3 involves the recruitment of the permanent director of the program and
bringing that individual on board.
In Phase 4, the director may choose to incorporate members ofthe initial Planning
Group into task forces that will work on further exploration of telemedicine and tele
health applications, urgent branding issues, a business plan and a host of other start-up
Planning a telemedicine and telehealth program is a complex process and involves
developing shared visions at a number of levels. The levels will include the leadership
of the organization that will house the program, (i.e., board of directors, deans for uni
versities if applicable, etc.) the management team, the customers ofthe health care sys
tem, and, ideally, the general public. Ultimately, the success of innovative health care
solutions may rest on achieving some level of support at each ofthese levels within the
Tracking progress in creating a community-wide shared vision for a new telemedi
cine and telehealth program can be challenging but a reward for doing so can be the
attracting of strong political support. Political leaders tend to admire cohesive visions
The Arizona Telemedicine Program has developed a methodology to guide a
member organization through a process aimed at developing shared visions for tele
medicine and telehealth within their own enterprise. There are many categories of so
called “shared visions.” These include such things as: shared visions of how to start a
new program; shared visions on the goals of a program; shared visions on resource and
risk sharing; and shared visions on the workplace environment. There are many more.
The following example concerns the development of a shared vision on the creation of
a new telemedicine and telehealth program.
RS. Weinstein et al. /Integrating Telemedjcjne and Telehealth: Putting It All Together
Figure 5. This figure lists components ofthe target shared visions for the start-up activities for a comprehen
sive telemedicine program. For a large, multi-organization program, this shared vision should periodically be
updated and reconciled with the constantly evolving visions ofthe member health care organizations.
Set I (groups)
Set 2 (tasks)
Figure 6. A vision matrix that can be used as a tool for designing and implementing telemedicine and tele
health programs. This methodology also identifies concerns and barriers as perceived separately by the or
ganization leaders and their management team.
In Arizona, as part of our planning process, we go through an exercise, which we
call a “Vision Matrix’ exercise m which leaders of each participating health care or
ganization and, at separate sessions, managers, discuss a series of tasks: goal setting;
establishment of priorities; articulation of a strategy to achieve each goal; and the de
velopment of formal implementation plans and schedules. Ideally, separate documents
generated by organizations’ leaders and their managements teams are then reconciled
and a joint vision statement (leaders plus management) is generated and circulated
The process involves having two separate groups: the organization leadership (in
cluding Board members, senior corporate officers, and possibly other senior stake
holders from the community, such as the CEO of a major company; and the organiza
tions’ management teams, including the Vice Presidents and division directors, meet to
discuss the proposed multi-organization telemedicine and telehealth initiative in broad
terms. Ideally, both service provider institutions and service user institutions are repre
sented. Under certain circumstances, the Vision Matrix exercise would take place twice,
initially with the designated Facilitator and the Consultant co-chairing the meetings and
34 R.S. Weinstein t al. /Integrating Telemedicine and Telehealth: Putting It All Together
a second time, after the Program Director has been recruited and can personally attend
the meetings. The primary goal of these meetings is to begin to develop shared visions
with regards to what telemedicine and telehealth might achieve in the service area and
to nurture the concept that there is plenty of room for collaboration among other-wise
competing institutions in the health care industry. We fmd that telemedicine and tele
health are natural conduits for communication among organizations which can be an
unexpected benefit ofa program.
In it’s full implementation, during the Vision Matrix exercise, the two groups, or
ganizational leadership and management, go through an agenda involving discussion of
four topics: goals; priorities; strategies; and implementation. These four topics are dis
cussed in sequence. Generally, each topic is discussed for about 20 minutes with the
Facilitator listing the participants’ points on a flip chart. The resulting list is then dis
cussed by the group for about 10 minutes before the group moves on to the next topic.
The Facilitator should understand that each of these topics is broad and could be dis
cussed for half a day or more, but be willing to resist temptation and stay with the time
line for the exercise. After these four topics have been discussed in the allotted time,
the groups break for an hour. They then reconvene for wrap-up comments and a discus
sion ofnext steps.
Our experience in Arizona is that many participants ofplanning sessions and train
ing events, although from the same geographic area, will be meeting one another for
the first time. They come away from such in-person sessions with an unexpectedly high
level ofrespect for the talent within the health care industry in their service area. Many
long term acquaintances have been established at Arizona Telemedicine Program train
ing programs and program planning events over the years. This has benefited both in
dividuals, in terms of career development, and the health care industry, in terms of cre
ating a shared sense ofmission for the health care industry in Arizona [2,3,19].
Why use the Vision Matrix exercise format? Telemedicine and telehealth are very
broad topics. In our experience, it is valuable to give health care executives and manag
ers a highly structured environment in which to hear about telemedicine and telehealth,
to begin conceptualizing its processes and to begin to understand the potential benefits
to their organizations, and to provide peer-to-peer settings in which to develop the
shared sense ofmission that can make a regional telemedicine and telehealth collabora
tive successful and sustainable.
With respect to the administrators of telemedicine and telehealth programs, the
program directors of such enterprises have complex jobs. They must have a clear vision
ofwhat they want their program to become from the outset, since all ofthe early stake-
holders will look to them for guidance and will remember early promises, as they
should. This does not preclude future growth beyond the original vision. Since tele
medicine is an extension of each ofthe participating member organizations, each entity
needs to have confidence in the director from the outset. The director should be highly
credible, with a reputation preferably based upon a solid track record of distinguished
accomplishments. Controversial individuals or individuals without suitable credentials
are disadvantaged when it comes to managing such public undertakings. Missionary
zeal and entrepreneurial spirits are desirable attributes. Individuals in leadership posi
tions in the telehealth world should demonstrate an unusually high level ofpassion for
what they are doing and function under the halo of idealism whenever possible. Creat
ing the future can appear intoxicating for the leaders ofthe charge for a new health care
technology. This is fine. On the other hand, hyper-enthusiasm should be balanced with
a willingness to be constantly challenged by technology skeptics. Political acumen is
R.S. Weinstein et aL /Integraiing Telemedicine and Telehealth: Putting ItAll Together
especially important for the telemedicine and telehealth program director in this regard.
Within the shifting sands of today’s health care industry, there are streams of disparate
messages that come to telemedicine program directors. Given the tense atmosphere
within the health care industry in the United States today, a program director needs
finely tuned antennae to pick up on subtle messages from numerous sources on an on
going basis and deal with them proactively and with fortitude.
The Planning Group should also weigh in on the selection of the location of a new
telemedicine and telehealth program within its organization. This may be especially
important for a university-based program since many diverse functional units may
choose to compete for the program. A common etror in establishing a telemedicine and
telehealth program is to place it administratively in an inappropriate administrative unit.
It must be emphasized that telemedicine and telehealth program are, first and foremost,
clinical services. At universities, a new telemedicine and telehealth program should be
assigned administratively to a clinical department. In our opinion, it would be subopti
mal to have a telemedicine and telehealth program administered within a non-service
entity such as a School of Public Health, although there can be extenuating circum
stances. A telemedicine and telehealth program’s business activities must be handled
by a competent medical business office, with personnel experienced in dealing with
billing and coding issues. At many universities, such business offices are housed in
The reader is warned that, in most cases, the program director should not be a phy
sician whose only special credential is an interest in computers. The successful candi
date should have experience that would qualif~’ him or her to be a medical service chief.
The area of medical specialization is remarkably unimportant. However, prior experi
ence in implementing and operating clinical services and overseeing medical business
offices is important. As part of the business and operations activities, contracts and
grants, reimbursement, procurement, licensure, and a wide spectrum of regulatory is
sues require attention. Generally, the program director should be an M.D. with an ac
tive medical license.
Today, given the current stage of technology diffusion of telemedicine and tele
health, it is helpful for the program director to serve the dual role of the program direc
tor and program “champion.” This is somewhat analogous to the desirability of having
health care system CEOs serve as both the public face and champions for their organi
zations. Championing a regional telemedicine and telehealth program can be demand
ing. Many stakeholders will lack a frame of reference in which to judge what is going
on and to understand the many hurdles being overcome simultaneously. Readers of
these comments a decade from now might find this observation outdated and even con
fusing but it all makes sense in terms of the fragmentary nature of telemedicine and
telehealth programs during start-up and ramp-up stages ofimplementation today.
Staff training programs should be instituted early on in the development of tele
medicine and telehealth programs. Although some of the training program components
may be applicable to other types ofhealth care services, it is important that many topics
specific to the practice of telemedicine be incorporated in the training programs. The
telemedicine training programs should cover special topics including: core competen
cies of telehealth providers; team building; outreach strategies; and the culture of “vir
tual communities.” The virtual community concept will be new, and even somewhat
mystifying to many employees being assigned to a telemedicine and telehealth program
for the first time.
R.S. Weinstein et al. IIntegrating Telemedicine and Telehealth: Putting It All Together
Training should include information on parameters that will be used as measures
of success for the telemedicine and telehealth program under construction. These
should include: meeting needs; achieving specific clinical outcomes; provider and ser
vice user satisfaction; and cost effectiveness. Financial performance can be considered
in terms of: revenue; coding issues; accounts receivables; patient mix; bad debt; and
network utilization. It should be understood, from the outset, that long-range strategic
planning for telemedicine and telehealth programs is important and includes market
assessment, goal setting, and the need for periodic updating ofthe program’s vision and
mission statements. Case studies can be effectively used in telemedicine and telehealth
training programs in order to provide context for the didactic material.
In the future, it is likely to say that telemedicine and telehealth services will become
commonplace and ubiquitous. In medical imaging fields, such as teleradiology and
telepathology, this may become the preferred way of delivering services. As these
teleimaging services move into the mainstream ofmedical practice, the “tele-” prefixes
might disappear. “E-health” has already become a term of choice by some practitioners
but that could become antiquated as well. Telemedicine may become synonymous with
Telemedicine and telehealth may emerge as global industries. Since the United
States has a fragmented health care system, it will not necessarily be the top interna
tional player in the telemedicine and telehealth industries, either in terms of technolo
gies or service volumes. However, health care’s superstar physicians, based in the
United States, may have advantages and be aggressively marketed as “big name”
brands within health care niches. Advertising dollars may pour into promoting the
reputations ofprestigious physicians who will carry a brand’s flag.
We also anticipate that patients will increasingly utilize direct access health care
services . Service integrators may play an increasingly important role in aggregat
ing health care services for patients . High quality telemedicine and telehealth ser
vices will be readily available over standard broad-band telecommunications networks.
High prestige institutions, such as John Hopkins, the “Harvard Hospitals” and the
Cleveland and Mayo Clinics are currently leveraging their well-established brand
names into international telemedicine and telehealth industries. They are advantaged by
their international reputations. Also, these high quality programs train many fellows
from other countries. They may return home to practice and become a source of refer
Telemedicine and telehealth organizations are not “business as usual.” The media of
telemedicine, including video conferencing and still imaging, magnify personalities and
performances, frame scenes, and effectively focus communication. The technologies of
telemedicine may also foster unexpected levels of cooperation and partnering with the
health care industry.
In Arizona, the Arizona Telemedicine Program brand is advertised as standing for
resource sharing and seamless technical interoperability among the state’s large num
R.S. Weinstein et at. llntegrating Telemedicine a,zd Telehealth: Putting ItAll Together37
hers of independent health care organizations. These notions resonate well in the Ari
zona State Legislature and in other governmental agencies. The success of the Arizona
Telemedicine Program’s ASP business models shows that economies of scale can be
achieved in the health care industry by bringing independent health care organizations
under a shared umbrella [5,19]. Although access to our teleconununications infrastruc
ture may provide the largest single economic benefit of membership for Arizona Tele
medicine Program members, the availability oftelemedicine and telehealth services are
the drivers ofthe membership model.
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