I want to first introduce, I'm Kathy Wasam. I'm with the Federal Office of Rural Health Policy. And some of you may be looking at the Navy uniform and saying, why is a Navy person here? Actually, I'm with the United States Public Health Services Commissioned Corp. We're a small officer group about 6,000 health officials who serve the federal government across a range of agencies in the United States. We serve on Indian reservation, we serve at the Centers for Disease Control, the National Institutes of Health, and also in time of war can be militarized. I came out from South Dakota to the Office of Rural Health Policy 10 years ago, I was kind of always their rule, their token rule, health professional in the federal office. I'm a nurse, and my background is in nursing. So, I've worked with the office for the last 10 years and for the last 5 years, I've worked on rural telemedicine and telehealth issues. Speaking with me today is Steve Hirsch, who is our web guru at the clearinghouse that our office sponsors in conjunction with he Department of Agriculture. It's called the Urban Information Center Health Service and Steve, a couple words?

Oh? Hello, everyone. I don't know what to say actually. I'm a librarian, I work at the Rural Information Center Health Service and I do the website which we set up I think it's now been about 2 1/2 years or 2 years and I'll show you what I can of website and what kind of information we make available, both over the web and directly to people who call us and to anyone who writes or uses e-mail to get in touch with us.

One of the things that I think the room is small enough that I would ask how many of you are from Australia, because I think there's a large contingent? Ok. So, from the United States? Just out of curiosity, have most nations been represented here at the conference? 45, oh, excellent. Ok. One of the things as I go through this is to remember and if you speak with colleagues later that kind of every country has a different type of telecommunications infrastructure. Some are more developed than others, and there are a range of technologies that we want to consider as we look at what will be most viable in different places. How many of you either have personally used telemedicine or have seen telemedicine being used? Ok, so about 2 of you. Ok. I'm going to move this around. On Monday, I wasn't sure whether I would be able to talk at all, so it's a pleasure, the voice is a little gravelly but I can talk. I would like to go over, and this kind of outlines what I will be covering with you today, some of the definitions of telehealth and telemedicine and I'll do that because I'll point out some of the issues that we've seen in the United States because of definitions. I have some videos to give you examples of what is currently being done in telemedicine and the range of technologies that are being used for that. I'll go over some of the key issues as they relate to policy and actual clinical use and then talk abut some resources. Unfortunately, the resources will probably be less pertinent to those of you from Australia, but it may give you an idea of where you may turn within your own country in terms of resources.

The Federal Office of Rural Policy has actually, which is where the telemedicine program has been based, the agency has just created the new office of the advancement of telehealth, recognizing the need to move forward and put more focus on it both for clinical practice and distance education. The office of Rural Health Policy is within the agency called the Health Resources and Services Administration which in our federal government is what I would call the access agency. It's responsible for helping insure that those who otherwise would not have access to health care, do have that access, and we do that funding clinics, both in urban and rural under served areas, by helping provide scholarships so that people will have a payback and thereby provide some of the clinical care.

The definition that we're currently using for telehealth is the use of electronic information and telecommunication technologies to support long distance clinical health care, patient and professional health related education, public health and health administration. You should know though it took a long time for our agency to finally begin using the term telehealth. At the federal level in the United States, telemedicine became the buzz word. And it became the buzz word in our Congress. And what happened when telemedicine became kind of the buzz word, it was like putting blinders on people. And people perceived that what you could do with the new technologies was like one doctor to another doctor with a patient. And they forgot about all the range of health services that you can deliver using these modalities. So they forgot that you could use this for physical therapy. For nursing care, and you'll see some of the different examples. I think that Australia, you've been fairly fortunate that it has been frequently been referred to as telehealth, in part, because of some of your leaders there. When you think of telehealth, you can use the technologies for clinical care. As I mentioned, we see physicians, nurses, dieticians, PTs, OTs, speech therapists, pharmacists, a range of personnel using this to deliver their services. It can be used for health professions distant education, both for continuing education once professionals are in a rural area and also we're now taking our degree out to rural areas so that rural individuals don't have to go into the university but we take the course to them. Many individuals tend to be more homebound, not homebound, but in nursing, many of the individuals we see going into nursing are women in their 30s and 40s, who have left opportunity to leave family, and so we're looking at innovative ways to use the technologies to bring education to them. Physical therapists, occupational therapists and speech therapists. And if any of you do have questions, please interrupt as I move along.

We have some very innovative things going on in consumer health education, funded both by the Department of Health and Human Services, but also some that the Department of Agriculture is doing to their different entities. And Health Services Information which is one of the things that Steve will be talking later about is not just enough to put a professional out in a rural area, but we have to have an infrastructure that supports that and how do we keep our rural hospitals, our rural clinics stable and functioning. A little bit about technology because again, depending upon the area, certain technologies will be more appropriate than others and so, we see innovative projects going on with just phones. We see phone systems that you could use, both still image and some very basic interactive video with and you'll see some examples here.

In the Untied States, we use the term pots, which stands for plain old telephone system. that's the basic copper wire, that has been built up to pick pretty much every home. But because of the constraints of how much information can be sent on that, there are only certain types of applications for which it's really appropriate. There are a range of video conferencing systems, some that are computer based, some that are basically much more video conference based. With computers, we've seen their use with test, with still images, with video clips and now we're seeing it with interactive video, some of the new compression technologies that allow us to use lower bank width. Different monitoring devices, and by that I mean devices that pick up human sign, so, for example, there has been a project, lung people, who had lung transplants go home, To measure the amount of volume or capacity of breathing with a spirometer. They do their reading at home. That information weekly gets transmitted to their clinician, and their clinician can see whether their may be any type of problem going on with the transplant. And then also peripherals and by that I mean many of our telemedicine, telehealth systems, you can take an oroscope with which you'd use to see the ear, you can take a stethoscope so that you can hear heart and lung sounds, so that the individual in the remote area, someone may put that stethoscope to their chest, and the clinician, wherever he or she is, can then hear what's going on. What I'd like to do now is show you four videos that look at different populations, that look at different technologies because again, there is not any one technology that will best serve all rural areas.

They want us to speak into the mike. The first one that I'll show you is from a system in North Dakota that we fund. And I'll show this to you because I think it points to more of the typical uses in terms of for medical care. But they also mentioned the other uses and provide you some background on how clinicians and patients perceive the technology. North Dakota is one of our more rural states, it's in the central. It borders with Canada. And there are approximately 600,000 people in the entire state.

[Video]

Does anyone have any questions on what they saw there before we go to the next one? Ok. When you say, cost of service, do you mean the technology itself or the cost for the actual service. One of the things is that in the United States, most of our service is covered insurance companies. With telemedicine, many insurance companies are not yet comfortable reimbursing for the service because they're not sure it's equivalent to in-person service. And so, what do we typically see is that the cost of the service provided would be the same as if they had, when the insurance company reimburses. The insurance company would reimburse the same amount as if it had been an in person visit. What we have done at the federal government right now, because we're trying to deploy telemedicine and see whether it works, we will provide the physician a $60 fee for the consult, and actually, we will provide any clinician who takes part in the consult up to $60. A lot of times that wouldn't cover what the clinician would normally get but they are also wanting to see whether this is a reasonable way of providing care and so agreed to accept that payment.

Ok. The woman who you saw with the short hair and said she was a physician assistant, her initial training was as a nurse, but in the United States, we have something they call a physician assistant, which is a little bit like a nurse practitioner, if you're familiar with those, but more medically oriented, less nursing oriented. So they have basic medical skills, they're not a full-fledged physician. They typically have a 2 to 4 year program to gain those skills.

Does this have to be in a hospital? Right, they said between medical facilities. I'm going to show you some different examples of how the technology is being used between different types of entities.

Right. Kansas was at the forefront of this. In Kansas, they've done a tremendous amount of cancer care with it, as well as a range of other services. So, that's true. Kansas is really...[someone asks question, inaudible] Right. Actually, telemedicine has been done since actually for the last 30 years when they began doing some telepyschiatry in Nebraska in the 1950s and we've seen kind of it come and go in terms of the systems get set up and then they die out because they can't be sustained given the transmission cost. There are some prophecies, there's activities on the way in the United States to try to bring down the telephone costs involved here.

The next one that I'd like to show you is between schools and clinics. And I think in many rural communities we may have a school and we may not have a clinic and in Kentucky, and this is a news clip that just came out about 2 weeks ago, so the quality isn't great, but I think it'll....

[Video]

The one you just saw doesn't require that live band with that the first one you saw required, but they use a computer based video conferencing system. The one I'm going to show you now, which is a home care, used the plain old telephone line. And so you'll see a difference in the technologies, difference in types of video.

[Video]

I'm going to show one last one. And it contrasts to these where it's an interactive video. The last one is a type of technology called casaphone that send only a still image. There's 2-way audio that can take place during it, and both parties can draw on the, for example, if there's an x-ray that they're looking at or an image. Four parties can draw on the screen so they can see the area that the other person is concerned about. It again functions over the plain old telephone. This project takes place again in rural New York and I'll only get playing a portion of it. We have a nurse practitioner on one end, a clinical nurse specialist, vascular specialist on the other, and they're now using the system with the public health nurse in the area.

[Video]

This unit is the Picasso. The monitor that they show the things on can be a TV, as long as it has a video feed so the key unit is the Picasso phone right there. I think that we'll stop there. He will be sending some images to her. I have a couple slides I want to show you, just to show you again, the range of technology that can be used for this. As soon as I find the little instrument with which to turn... there we go. Ok. Some places and many parts of the world we don't have telephone lines reaching it. When the United States was in Somalia, one of the things they did was they did still image transfers using the satellite. And at that point, what you have in this picture is your satellite uplink, the laptop upon which they did it, and they used to use the monitor. They don't need the monitor any longer so all they need is the laptop computer with the satellite uplink to be able to transmit images. Let me give you a sense of the images that they transmitted. In the bottom left hand corner is the image of a finger which gives you the sense of how well the quality of the image is. The top pictures are 2 colleagues at the Walter Reed Army Medical Center where they received and read the images. So in some parts where we don't have the phone lines reaching satellite technology is the alternative, and I think in Australia, we're all very familiar with that. Again, these are some of the images sent. This is a telemedicine studio in Norway close to the Russian border. And again, it gives you the sense that telemedicine systems vary dramatically in terms of how they're put together. But this had 2 videos. The microscope under which they would transmit pathology slides. A camera for skin wounds. This is another system we have in Minnesota. It's a small room outfitted with the telemedicine system. This is a picture in Sweden. In many of our communities, the technology may not be available in a hospital or in a clinic, and in Sweden what they did is they said, well, you know, we have all this interactive technology available down in the local high school, so why don't we just, when need be, take the patient down to the local high school, hooked the University of Tulas and do our consult that way. And that's how they started. And after a year of doing this, the county government decided well this seemed like a worthwhile investment, which they weren't initially willing to look at. You know, it seemed too expensive, and they've now actually put in the telemedicine technology in the clinic there. But in many of our schools, we'll see more and more of this technology go in and we shouldn't overlook those systems as using them for health care.

This again, is the picture of the home telehealth care unit. This is the unit that actually sits in the patient's home. The image is only about a 2 1/2 by 2 1/2 video image. In their latest version, it's a 5" screen. This again uses a regular telephone line and you can do heart and lung sounds. There is technology now being used for home health visits that you hook to your regular tv. There's what's called sea phone and 8 by 8, a unit that costs about $500 and provides interactive video, although it doesn't provide the opportunity to do heart and lung sounds.

This is the unit that the nurse uses, the home health nurse in the office or in the home. And the little person peeking over the should was my son who has accompanied me on many telemedicine site visits. Ok. And if we could have the lights again.

Does anyone have any questions on the last couple of videos that we saw? Ok. Just to reiterate. We're seeing these telehealth systems being used in inpatient care and emergency care, for outpatient clinics, in Oklahoma, they've put a telemedicine system in a mobile van and they drive that van to rural communities and they hook it up when they get to the rural community, so again, instead of everybody having to have a system, it's a transportable one. We're seeing it in homes, in nursing homes, this may be perhaps less pertinent to rural, it's still, in many places, an issue. We're seeing them being used in homeless shelters, schools for K to 12 you saw Kentucky. Kansas, again, has been at the forefront, they actually have an urban school project underway. One of the key or dominant uses in the United States of our telemedicine systems is for mental health care. And in Australia, you also have some very outstanding telepsychiatry programs under way. And we're seeing it being used in group homes and in by group homes, I mean, homes for the developmentally disabled where individuals may need care, may have a particular mental co-founding problems. So, basically, anywhere we have individuals who were using it.

I'd like to just very briefly cover some of the issues in the United States that may be issues in other area. The first one if licensure, which, as I understand, is not an issue in Australia. In the United States, every health professional is licensed within the state that they practice, so if you do a consultation between two states, the individual should be licensed in the other state, and so one of the things that's been perceived as a barrier to telemedicine, although there are at this point, not that many telemedicine that cross state line.

Payment. Payment is one of the big issues. If I'm not going to be paid to do this consult, why should I bother to do it. And as I said, more and more of our insurance companies are becoming willing to reimburse for it, but it's not at a national scale yet. Our health care financing administration, which is the part of our government that pays for care for the elderly, for those 65 and over, medicare, has up to this point has not been reimbursing because they didn't feel they understood enough about what goes on in a telemedicine session, to say that the care was equal to care provided in person. A year ago, they started a small demonstration program of reimbursing at some telemedicine projects that they previously funded. Two weeks ago, they published a regulation because a year ago, Congress passed a law that said by January 1, 1999, PICFA has to figure out a way to pay for telemedicine consultations in rural health professional shortage areas. For any of you from the United States, if you would like a copy of that regulation, I have it at the front here because I think it's critical that rural communities know that it's out and that's it's responded to. I'm not sure that it addresses some of the issues in rural America here. Let me ask you then, Australia. How re you services covered when they're done via telemedicine? They're not reimbursed? Ok. And has that been a problem in terms of clinicians willingness to use them?

Marie might know more about this. Kind of still is an issue in Australia because the doctors must consult the patients one on one and as of yet, it's not recognized as a one on one. But, do you know what it's like in South Australia? I'm sorry we can't help you on that issue.

One of the things in the United States, PICFA currently has a study underway, an evaluation study and our office of Rural Health Policy will begin a study this fall that will look at some of the issues to answer some of the questions that insurers ask in terms of telemedicine. In the United States, Medicaid, which is the federal program, it's a federal, state program to pay for health care for individuals who are below the poverty line. Or who are disabled. Reimburses for telemedicine is about 12 of our states and part of the reason that Medicaid has been willing to reimburse is because Medicaid reimburses for transportation, so if they're an individual in a rural area who has to travel 3 hours to an urban center and then stay overnight, Medicaid comes out ahead cost wise when they're able to pay for the consult if it takes place in a rural area. There are kind of legal issues in terms of if the equipment fails while I'm doing a consult and something happens, I misread an x-ray, who's liable? There are also standards, in terms of does this change the standards of care for nurses, for physicians, if so, how? There's also in the United States is the issue of the telecommunications infrastructure and in 1996, our telecommunications act which governs telecommunications services was revised for the first time basically since 1934, any major revision. And one of the reasons in the United States that are rural areas have telephone services because in 1934, the legislation said that we will create, you know, everyone should have universal service. Meaning, a telephone into every home. And to do that in rural areas, they needed to set up a pool a money to basically subsidize that because the cost of providing telecommunication services is so much higher in rural areas. And that was called the universal service on all the telecommunication carriers has to chip into the fund and those dollars were then used to support the infrastructure and the cross to the service in rural America. When the telecommunications act was passed in 1996, they said, well, we used to consider universal service a one party line. Now we need to look at universal service as the advanced telecommunication that currently undergirds our economic business in the United States. And so there are new subsidies available specifically for schools and libraries and for rural health providers. Unfortunately, that's come to be seen as a tax and there's a movement foot to basically eliminate the support for the school's libraries and also potentially for health providers. Some of the other issues have been the clinician patient acceptance. One of the things that we've seen is that patients almost across the board have liked telemedicine, and although all things being equal would prefer to see their clinician in person if it means a tradeoff of a 4 hour drive, losing a day's work, they find that for most of their health needs, they're able to achieve their desires through telemedicine.

Effects on health care cost. One of the real concerns is well if all these people haven't had access to health care before, what will it do to the overall cost in the United States? Part of the reason our health care financing administration has been very reticent, they say we're going to be reimbursing for this, because they're very concerned about what it can do to the overall cost in the federal government. Under most of our insurers, no. And so, part of the problem becomes with, who saves? And so, for example, in Norway, even although the system was funded by the Norwegian government, is we didn't have to do a air transport, the part of the government that saved that cost wasn't the one responsible for health care and so, even at the federal level sometimes you kind of jimmy about who saves and where those savings occur. One of the things with the home care with the chronically ill patients, is there is some studies underway to look at whether if you can monitor people more effectively at home. Do you prevent emergency room visits? And do you prevent repeat hospitalization. Some of the date coming out from studies in Minnesota and in California are able to show that they do decreased the emergency room visits and they decrease hospitalizations because they pick things up sooner before the person gets so ill that they need to be hospitalized. One of the things that we hope to capture in some of the evaluations is where are the cost savings? To who do they accrue? And hopefully, use that to again encourage insurers to cover the cost. Right, but sometimes, those, that again, is handled by perhaps a different entity and so those, it doesn't get looked at as a real savings to those who typically pay the cost. I think we may see more use in managed care. I'm sorry, closer like this?

If it's being used as an educational tool, surely it has to be a plus as far as preventive care rather than emergency or...

And so, as I said, it's still the issue of who pays to who, do those kind of plusses accrue? In our managed care systems, I think we may have more of a chance of showing how, kind of costs are contained because of it. But, there is a lot of study that still needs to be done. We're seeing uses in the military, which is more of a closed system and we may get some good data from those centers.

I'm just wondering about overuse. If you have patients who can have their anxiety relieved by a facility that's very convenient, will it be used unnecessarily or have you had any experience with that kind of an issue?

We currently haven't had experience that I've seen in the literature about that. I would agree that it may be used out of anxiety, but in a couple of the projects that we have underway in Missouri where they're using it for hospice care, those families are very anxious and frequently the patient is very anxious. And I'm not sure you could say, will it be overused. It may be used over to the point that the anxiety is decreased so that they don't take that patient into the emergency room. But I think that is one of the things we'll want to look at.

Just in terms of your home health care, what affect is it having on the other family members? Like I saw that with the critically ill patient, the other spouses that are taking care, taking measurements, how are the patients coping with their close family relatives taking difference measurements?

That hasn't been raised an issue yet that I'm aware of, but that's not to say it hasn't been raised as an issue. In the one slide that I showed of the home health nurse, I was in on a visit to the patient and this was someone who was basically homebound because of crippling arthritis and she said, now that I have this system here, my husband, it feels like he can go out and visit with his friends. And what I see happening there is that it's helping the caretaker take care of the individual longer because they can get away. And so it may provide a plus in that sense.

If I can make a comment on that, I work in hospice palative care and I live quite a distance from a regional center. I think the positive fact is if a person can stay within their own home, it lowers that stress level incredibly and if a carer can do a lot of those things, they're very, very grateful.

They may be anxious originally doing them, but if they can have some video contact so that they're assured that they're doing them correctly, again, I think that, then they're willing and able to continue.

It lowers the stress for both the carer and the patient.

I mean, if you're the patient and you feel like you're family member is not doing the right thing, then, yeah.

But does it really lower the stress in the care he or she may feel that they have too big a load now?

Again, those are some of the research questions that we really need to look at closely, because the more care we take into the home, the more burden it can potentially become for someone, yeah.

As a carer, I can tell you it would have alleviated a lot of traveling and a lot of anxiety you do get that feeling, should I go home now or should I stay a little longer, when you know there are things got to be done at home and you're drawn between home and the patient and it's insoluble after a few months because home just is building up and the patient is demanding more.

Ok. I think with that, I'll end my component and Steve is going to over with you the types of information that we're now looking at providing our rural communities, our rural individuals. When I look across at you, what I see is kind of the hopes for rural areas, because you will be those leaders in rural areas, so make sure that the health care systems remain what we have seen in the United States is when you begin to lose a hospital, you frequently begin to lose other components of your community. So, when I look at telehealth, I think of it not only in terms of individual health or the health of the families, but actually the health of our rural communities. So, Steve? I noticed that the acronym is riches, I always say riches from riches.

Thank you. And that's what it stands for. Rural Information Center Health Service. Let me grab something else. Which has been in operation about 8 years now. I haven't been there that whole time, I've been there about half the time. We are part of a Department of Agriculture Information Center called the Rural Information Center, which is located at the National Agricultural Library, which is about 14 miles from here, up the road in Maryland. We're not in a rural area, but we have worked hard to make the information we have available to people in rural areas, and I'm gonna talk mostly about how we do that. The Rural Information Center works on Rural Economic Development and providing the same kind of information and services in that area that the health service does on rural health care. We're funded by the Office of Rural Health Policy and the law that created the Office of Rural Health Policy required them to have an information clearing house and they took a creative view of that, because the clearing house could simply be somewhere that people call to get ORHP publications, I'll just call them ORHP from now on. But instead, ORHP decided to take a broader look at what kind of information people in rural areas needed on health services. We don't provide any clinical information whatsoever, but we do provide information on, well, let me show you. We provide reference services, that includes general information services such as literature searches of bibliographic databases. We generally use Health Star, which is a database produced by the National Library of Medicine here and also by the American Hospital Association. It covers literature on health care planning and facilities. We also have an extensive collection of materials that we've collected over the last 8 years. It includes books, articles, news letters, government reports and working papers from rural health research centers around the country. Our most popular service is the funding searches because people call us looking for money all the time for funding to provide a service or to create a health facility and we tried to locate funding sources for that, either in the federal government and we have access to what's called the catalogue of federal domestic assistance and it's available on line, on the world wide web, it's a listing of financial and non financial assistance programs offered by the federal government. We also use something called the foundation directory, which is a CD rom database of more than 25,000 grant makers, including private grant making foundations, community foundations and corporate grant makers.

Are those foundations limited to the United States or do they include other countries also?

They do include other countries. Some of the foundations are really county level, they're only found in one county, others fund across the state and some fund national programs, and some fund international programs, and depending on where people are located, we can help them. However, we generally don't take international calls, it's just the way things are set up, that we concentrate on the United States and rural health car in the United States and that's a plenty big area for us to cover, just trying to keep track of that. We also provide referrals to national organizations such as National Rural Health Association or the National Association of Rural Health Clinics. And one of the things we try to do is collect examples of model programs in rural areas, so that if somebody's thinking of starting up a program to provide services to HIV infected people in a rural area, we try to already know about such programs that are going on and provide them with information on how the program works and who to contact there to get more information. Now, we make information available through regular publications and like I said, our funding publications are probably the most popular. Rural Health Services Funding, Capital Assistance Funding. We have some copies of that up here at the front if you'd like to pick them up. Managed care has been a big issue for the last several years. Are those of you not from the United States familiar with managed care? No. It's hard to explain in a few words, but it is an organized system of medicine, what we call vertically integrated, going from primary care to tertiary care. Before managed care, patients were pretty much free to go visit whatever doctor they wanted to see, for whatever reason the patient thought appropriate. One of the features of managed care is to use a primary care provider, and the patient is supposed to go to their primary care provider and if necessary, then receive referrals to specialists. This is supposed to save money by limiting access in a way and preventing unnecessary usage of special services. You too? Ok. It's called managed care here.

Mid level providers, which are the physician assistants and the nurse practitioners that you saw, that was another popular publication that we have. Let me get more into our services that are available over the internet. How many people have used the internet here? Oh, good. And the world wide web, I take it. When I came to the Rural Information Center 4 years ago, we were using a bulletin board system. Are you familiar with bulletin boards? Using a computer in a modem, people could dial in. Now, most people access us through an 800 number, which is a toll free number. Anyone in the United States can call the 800 number 8 1/2 hours a day during the week somebody's staffing the number. During the weekend or at night, there's an answering machine and we will call people back. It's free. For the bulletin board system, it costs, there were long distance charges associated with calling into the bulletin board system, and it was the worst bulletin board system I've even seen in my life. It was awful to use it, it was not user friendly, and before long, we moved things onto a gofer, which was a sort of precursor of the world wide web. It was a totally text based system using a menu. And that was pretty good for our purposes. It was far easier to use than the bulletin board, but now we have moved onto the world wide web and as I said, it was about 2 years ago, I think. This is the main page you came to and they're examples of it at the back that you can pick up and take if you like. This is the most complicated page we have. Probably is you've used the world wide web very much, you've seen all sorts of fancy graphics and spinning things and animations, and we don't have any of that and it's not just because I don't know how to do it, it's also because we are aware that there are people who are connecting to the internet making a long distance call still even if they have to call within their state to get to a node, and they don't want to sit there and wait while a fancy graphic downloads for 10 minutes over a slow connection. I'm hardwired in the library where I work, I'm hardwired into our network and to have a graphic load, it takes at most a couple seconds, but when I'm at home and I'm connecting over a fairly fast modem, it could take still a minute, and if it's a slower modem and it's somebody who's way out, it's gonna cost them a ridiculous amount of money. And they don't want to sit there and wait while some graphic downloads, unless it has some information that they need. So, these are the fanciest graphics that we have on our website.

Now, let me tell you a little bit. We do not have, as I said, clinical information. Our information deals with health services, how to fund them, what kinds of programs are out there, and so we have concentrate from the beginning, on being a content rich site, a place where people can go to get information about those things. When I started using the web, I noticed that if you went to a site frequently, it was a collection of links to other sites, and you click on a link and go to another site and it was a collection of links of other sites. And there wasn't a whole lot of information and the very first thing we tried to do on our site was put up a lot of information, so people could come there and find what they needed. Now, as I said, funding is our most popular resource and service and so we have one page devoted especially to funding. Now, we have a series of bulletins that we update twice a month. One of them is called Federal Grants Relative to Rural Health and that's updated 2 times a month. I'm always looking for federal grant programs to supply funding for rural health programs. We I find one, add it to the bulletin, as I said, it's updated twice a month. Hundreds of times a month, people access that to see what's new and what's available. We also have a bulletin just devoted to the foundations that support rural health care as well as links to other kinds of funding sources. So, here's the bulletin, this is the federal grant bulletin. This is from several months ago when a distance learning in telemedicine grant program was announced. It was announced in the federal register which is a sort of daily compendium of items from the federal government and I include who's doing it, rural utility service and a scope note on what it is meant to fund. 12 1/2 million dollars in grants and 150,000,000 in loans, but most people apply for grants rather than loans because they don't want to have to pay it back. One of the other bulletins we have is upcoming conferences relevant to rural health. And this was just updated the other day. It deals with Indian health care, anything that looks like it's relevant to rural health care.

Besides that, now we have started putting on information resources by subject areas; agricultural safety and health, as well as the other ones you can see, rural health centers and clinics, rural hospitals. That is more or less of a links to other areas, here's one on hispanic and latino health. We're becoming more interested in minority health care in rural areas and most of these, while we provide links to some full text sources on the web, we also do links to other sites that are of interest. The internet is vastly changing the way we do things, because we can put up so much information on the web full text, and anyone can access it at any time. They don't have to call us between the hours of 8 and 4:30, they can access it any time, night or day, and received the entire text. This is, I think, pretty good. It's really a good thing. It's available at the patron's convenience and I guess the most important thing is that we still are available to them for free suing the 800 number. Now, some libraries are using the internet to put things up on the web and saying, now, we don't have to deal with people anymore, they can just, it's true, I hate to say it, but... Now, they don't have to call us, we can just tell them, go look on the web and find it. We're not going to do that. For one thing, the interaction with the people who call us allows us to find out what they're interested in and a lot of the time, the publications that we have developed over the years, like the one on managed care we developed because people were calling us all the time from rural areas saying they don't have any experience with manager car out there, because manager car companies have concentrated on urban areas. And they want to know, 1) what managed care is about and 2) what form it could take in a rural area. So we put together the publication Our Managed Care in Rural America to try to provide as much information as we could pull together on that subject area. So, for the foreseeable future, we will continue to be available through an 800 number for free any time people want to call us as well as putting all this information up so that people can access that at any time and get the full test immediately, rather than having to wait for us to mail them something. Now, as I said, one of the favorite things that people hear about is that we are free, and that's because the Office of Rural Health Policy has been very supportive of what we do and made sure that we provide this information. One of the things I do is also run a website for the Office of Rural Policy and this is it. It allows them to put up notices about their grant programs and they have several grant programs. One which has dealt with telemedicine, another deals with outreach in rural areas and that has included health education among many other rural health projects. And they've also used it to put up full text which is an article that appeared in a book, of which Kathy was one of the co-authors dealing with telemedicine in rural areas.

So, are you aware of anything similar in Australia, is there an information center that you can access too? Oh, well, as I said, we do outreach as well and we go out to try to alert people to our presence and that we are available to them and that all of our services essentially are free to them. They can call us and we do the funding searches, we do literature searches, it is individualized so that if somebody calls us, we do something that is right on target for what they're looking for. It's not a precanned thing that we just print out another copy and send it off to them. It is specific to what they are looking, the information that they are seeking.

Now, as long as so many of you are here from Australia, I have to say, I'm a librarian, and I wrote my masters paper on an Australian man named John Edwards and if anyone has ever heard of him, I'd be happy to ask them questions, I have some questions about him. No. He died in 1960, but anyway. Ok, all right. Do you have any questions about what the kind of information that we put up or our services to people in rural. We don't only serve rural people, I should say. One of the things we do. A lot of nursing programs, student and nursing programs call us and ask what's it like out in rural areas to, how can I find out about practicing in rural areas? And that is a large part of what we do is working with practitioners who are interested in working in rural areas. Well, there's plenty of rural areas, believe it or not in the United States. 80% of the land in the United States is considered rural. It may be. There may be more frontier areas which is really low population per square mile in Australia, I think that, far more, than in the United States.

I have a question and that is. If one of the individuals in the audience had a question and they're not asking for a big funding search because obviously, that probably wouldn't be very pertinent, but another issue, there's nothing that would prevent you from providing that service to them, is that correct? Via e-mail, we have had requests from other countries and we're happy to help and especially if you're interested in American rural health care, because that's what we know about. I guess occasionally, I've had a question where somebody inside the United States calls and wants to know about health care in another country and I try, but it's not an area that we have a lot of information on. However, we do have quite a bit of information on agriculture safety and health that we've collected over the years, and on women in rural areas. So, hopefully, we have information that people at this conference could use.

Ok, just a couple last things that I'd like to conclude with and that is, on the publications in the back, there are 2, one on websites and one on federal publications related to telehealth. At the end of both of those you'll find some of the sources that I knew in terms of other countries. So, they're a couple things referenced for Australia, some websites for France and Canada and Australia. At the front here, we just recently put together a federal telemedicine directory and these are all the telemedicine, telehealth projects that the federal government has funded from 1994 through 1997. If you would like a copy of that, it's listed on the publications list, and you could request that we send a copy. The other thing is, I will give this to one lucky person from Australia, and you should feel free to copy it for your colleagues. But, will you do that, if I give it to you? There is another publication called Rural TeleHealth, telemedicine, distance education and information for rural health care. We're putting our a revised one later this summer, but what this is good for, is it has a very down to earth explanation about the technologies, the transmission modes and then it gives you some examples and it has a fairly good glossary. We have found it very helpful for individuals who are considering getting into telemedicine. Also listed on the report publication that's at the back is the state of Kansas, about 4 years ago, put together a 4 volume report on telemedicine and the 3rd volume of that report is kind of a community assessment guide. If a community is considering basically putting in a telemedicine system and that full volume report is also available from the Kansas State Office of Rural Health for I think about $20 and there's an address there is anyone should want a copy of that.

Just a couple other things, but again, this will probably be of less interest to those of your from Australia, but a new publication from our office that looks at kind of what our rural areas are and goes through a range of health issues. At the back, there were the chairs on which publications were place. Also on the back table are 2 additional publications. One that lists all the telemedicine, telehealth projects we fund, gives a brief description of them. And also gives contact names and numbers and then there's also the executive summary from the telemedicine report to the Congress that was published in January of 1997. One of the things in the United States is because we have so many federal agencies involved in telemedicine from the Department of Agriculture, Department of Commerce, the Department of Defense, the Department of Energy, we have established a coordinating committee at the federal level to trade information so that we begin to look at how we can perhaps at the federal level work more closely together to get the bigger bank for the buck. And the report to the Congress actually came out from the joint working group on telemedicine which is the name of that group. Do you have any kind of coordinating group or counsel in Australia to look at what's going on across the states and the federal government. I think it's been something that's been very useful here in the United States and if anyone, you know, is interested in taking that back and also kind of connecting with us again to look at what we've done with it, the acting director of my office, Dr. Deanna Puskin, chairs that committee. Let's see, there were just 2 other things that I wanted to, I think, mention. Did you have something?

Most of those publications she mentions are on the web so if you access either the ORHP page or our page, you can reach them through there.

That's right, the telemedicine report to the Congress is on the web. The PRIMA, rural telehealth isn't on the web yet, but when we have our revised version, we will be putting that up.

One of my questions to you is, when you take this information back to your communities, is there a way that you want to continue some type of dialogue with our federal government or our office as we move forward and begin? One of the things that I would like to see is there a way we can more effectively trade information on evaluation projects you may have underway in telehealth, so that we're not kind of all reinventing the wheel as we move forward.

I know our western Australias in the Department of Commerce and Trade are very, very interested to have any information that you might have, if I can give your name after, if you wouldn't mind.

And again, when you go back home and begin to think about this, if something comes to mind that you would like to explore further, my name is on the bottom of the web publications with a contact e-mail address also. So, we would love to hear from you as we, in our agency, move forward with the office for the advancement of telehelp.

And I'd like to close with a saying that was inscribed on a Church in Sussex, England, back in the 1700s. It goes like this. "A vision without a task is but a dream, and a task without a vision is a drudgery. A task with vision is a hope of the world." And I thinking what conferences like this conference do, is that they being us together and we can being to build vision together but also begin to define a task together and that is really the hope of our rural communities no matter where those communities are. So, I wish you all the best and for those of you who've traveled in, safe travels home and again, please feel free to contact us if there's anything we can do.