Northeast Missouri Telehealth Network

Project Summary

This project was initiated in July 2005 and completed in March 2009. Team efforts led to successfully meeting the goal of improving access to care for the underserved of rural northeast Missouri utilizing telehealth technology.  Even though this regional project has ended, the telehealth sites are still functional and available for health care usage.  Community members should speak to their health care provider about use of telehealth for routine health care visits.  Missouri Telehealth Network will continue to function as a resource for each site and provide direct support to the sites.  Site listings and contact information for MTN sites in the state of Missouri are available on the MTN website.  Multiple continuing educational events are available via telehealth and schedules with topic information are available on the MTN website.

Network Description
The Northeast Missouri Telehealth Network, a grant funded program of A.T. Still University in Kirksville, Missouri, worked to improve access to high quality primary, specialty and mental health care for the underserved of rural northeast Missouri via telehealth technology.  Project partners included members of the telehealth committee which represented multiple health care agencies in northeast Missouri, the Northeast Missouri Rural Health Network (NMRHN, www.nmhrn.org), the Missouri Telehealth Network (MTN, www.telehealth.muhealth.org), and the Northeast Missouri Area Health Education Center (NEMO AHEC).

Project Objectives
The three main objectives of this project included: 

1. Establish and expand site-based telehealth primary, specialty, and mental health care services in an 11-county area of northeast Missouri;
   During this project period from July 2005-March 2009, 15 new telehealth sites were developed of which 14 were still functional as of project end.  Including the five pre-existing telehealth sites, this led to a total of 19 sites in northeast Missouri.   A total of 1,456 clinical encounters occurred via telehealth because of this project.  The telehealth network was also used for health professional education and health care administration.
2. Conduct comprehensive provider/staff recruitment and training to maximize utilization of the newly initiated telehealth system in northeast Missouri;
   Site coordinators were identified at each agency site.  Initial and ongoing training and support was provided to assist the Site Coordinator to be the telehealth champion at their agency.  Provider recruitment resulted in 19 providers registering and participating in equipment training.  A provider directory was developed and is maintained by Missouri Telehealth Network.
3. Reach 50,000+ people with educational messages to raise public awareness about the availability/benefits of telehealth and improve consumer use of this health care service.
   Multiple media avenues were utilized to reach greater than 50,000 people and share information about telehealth and its availability with the residents of northeast Missouri.  Efforts included:  Advertising via radio, TV, newspaper, and billboard; Telehealth DVD; Press coverage for events; Community education programming; Open houses; Website; Public presentations and Participation in community events.

Project Region
The counties impacted by this project covered an 11-county service region, including Adair, Clark, Knox, Lewis, Linn, Macon, Putnam, Schuyler, Scotland, Shelby, and Sullivan.  All targeted counties are designated as geographic/low-income health professional shortage areas (HPSAs), low-income dental HPSAs, and mental health shortage areas.  Marion County was included in this project during Year 3 when a telehealth site was added in Hannibal.

Funding
Funding for this three-year project was provided in part by the Missouri Foundation for Health.  The Missouri Foundation for Health is a philanthropic organization whose vision is to improve the health of the people in the communities it serves.

Disaster Preparedness Project

MTN, the Missouri Department of Health & Senior Services and the Missouri Primary Care Association joined forces in a public health and emergency project to digitally link all Missouri hospitals and community health centers together. The network supports delivery of disaster preparedness programs and acts as a mechanism to remotely provide clinical services during disasters. This effort is funded by grants from the federal Health Resources and Services Administration (HRSA - CFDA 93.003) to the Missouri Department of Health & Senior Services.  At the completion of this project 19 new hospitals and 16 new community health centers were added to the network. For more information regarding the Missouri Department of Health & Senior Services visit www.dhss.mo.gov and for the Missouri Primary Care Association visit www.mo-pca.org.

Missouri Telehealth Resource Center

The Missouri Telehealth Resource Center (MTRC) was established to 1) provide new members of the Missouri Telehealth Network or of other telehealth networks the opportunity to learn about the technological, clinical, educational and administrative aspects of telehealth and 2) to expand telehealth services throughout Missouri.
The MTRC was funded by a State appropriation from the tobacco-settlement money. Any site receiving State funding for telehealth was required to attend the formal training sessions in an effort to jump-start the telehealth program at that site. A formal training center and curriculum was developed in 2003. The curriculum is outlined in the attached agenda (Agenda), (Adobe Reader).There was also a formal curriculum which was bound and given to the attendees. The training was typically a two-day program, but in some cases the MTRC provided a one-day program. At the end of each training day a formal evaluation of the program was completed by each attendee. The MTRC hosted 6 programs and 140 people were trained.

The MTRC also allowed one of the most underserved populations in Missouri to have access to health care through telehealth. The Southeast Missouri Health Network and MTN worked together to successfully integrate telehealth into their clinical services. Patients were and still are seen by specialists at the University of Missouri Health Care through telehealth. SEMO Health Network has videoconferencing equipment as well as peripheral cameras at 5 FQHC's. The clinics are staffed by physicians and nurse practitioners. Nurse practitioners use the videoconferencing equipment to collaborate with physicians at the other clinic locations. It is also used for administrative meetings to reduce travel costs. Though the funding for ongoing telehealth services for these sites has shifted from the MTRC to the Missouri Primary Care Association (through grants from the federal Health Resources and Services Administration to the Missouri Department of Health and Senior Services), the MTRC was the sole funding source from the onset.
In addition to these 5 telehealth sites the MTRC funded 6 behavioral health clinics located throughout mid-Missouri with telehealth services. These clinics provide an array of services which include individual, family and group counseling, case management, medication management, psychiatric evaluation, assessment, etc. The behavioral health staff traveled to these clinics to see clients adding expense as well as unproductive use of the staff's time. MTN with funding from the MTRC partnered with them to add videoconferencing systems in their offices locally and in their 6 remote sites to save them both time and money. The MTRC also funded the use of telehealth in 2 community mental health centers in southwest Missouri.

Additional telehealth sites were added locally within the University of Missouri Health Care through the MTRC funding. With the addition of these sites telehealth was made more readily available and easier for physicians to access, since the telehealth equipment was placed in the clinic rooms. As a result, the number of patients seen via telehealth increased as well as the number of specialties available.

Office for the Advancement of Telehealth
Rural Telemedicine Grant Program

A portion of the Missouri Telehealth Network (MTN) was a rural telehealth project jointly funded by the Health Resources and Services Administration's Office for the Advancement of Telehealth (OAT), the University of Missouri Health Care, and rural healthcare providers. The project had two major objectives: 1) to provide high quality specialty care in participating rural communities through the use of digital telecommunications technology; and 2) to evaluate the clinical utility and cost impact of telemedicine.

The targets of the project were rural communities in mid-Missouri. Three of the project's counties were designated as Primary Care Health Professional Shortage Areas, but all of them lacked specialty resources of the kind provided by MTN.

Telehealth sites were equipped with interactive videoconferencing equipment, teleradiology equipment or both. Sites with interactive video were typically equipped with document cameras, video scope systems and electronic stethoscopes as needed. High-speed digital phone lines (T1) transported the audio and video transmission. Specialty services were provided in the areas of Adolescent Medicine (eating disorders); Autism Clinic; Burn Clinic; Children with Special Needs (Dept. of Health Psych); Dermatology; Endocrinology; Genetics Follow-up; Internal Medicine; Medical Ethics Consultations; Missouri Occupational Injury Clinic; Neurology; Physical Medicine & Rehabilitation; Provider Consultations with Geriatric Specialist; Psychiatry Child Health; Radiology; Rheumatology; and Surgical Follow-up.

Sites: The OAT funded portion of the Missouri Telehealth Network (MTN) connected the following 18 sites via an interactive videoconferencing network and PC-based data network:

• 1 Federally Qualified Health Center
• 5 Critical Access Hospitals
• 5 Primary Care Clinics
• 3 Hospitals
• 1 School of Medicine
• 2 Multispecialty Clinics
• 1 Nursing Home

Telecommunications: The entire Missouri Telehealth Network (including the OAT funded sites) used T1 (Frame Relay) connections to each site. These connections provided dynamic bandwidth allocation for voice, video and data. MTN sites had the flexibility to call any other MTN site directly in this configuration.

Services: On average, the OAT Rural Telemedicine Grant Program sites provided the following services per month:

• Interactive Exams: 23
• Teleradiology Exams: 425 to 450

Rural Telemedicine Evaluation Project (RTEP)

In 1996 the Rural Telemedicine Evaluation Project (RTEP) funded by the National Library of Medicine (contract #N01-LM-6-3538) expanded telemedicine services in three existing MTN communities. The major objectives of the project were:

• Study the costs, benefits and other effects on rural health care of integrated telemedicine systems based on the National Information Infrastructure (NII).
• Implement a local digital infrastructure, based on commercially available technology, linking all major components of the health care delivery system in three rural communities (Boonville, Macon, and Brookfield, Missouri), and connecting them to the University of Missouri Health Sciences Center (MUHSC) and to the NII.
• Deliver a well-integrated and secure set of telemedicine services through the projects infrastructure and the NII, including an integrated World Wide Web based interface to major telemedicine resources, health care database access, clinical information systems, email, and other forms of telemedicine, based in part on the assessment of the specific needs of health care providers in participating communities.
• Provide the training, management strategies and technical support needed to enable rural health care providers to adopt and effectively utilize telemedicine services available through the NII and the infrastructure provided by the project.

The RTEP Workstation, a World Wide Web (WWW) based interface was created as part of the project. This interface allowed physicians, nurses and other users to access e-mail, the National Library of Medicine databases, important health related websites, order reprints from the J. Otto Lottes - Health Science Library (MUHSC), and to check patient records at the MUHSC. The RTEP Workstation was also customizable so that the user could bookmark their favorite websites. The development of the RTEP Workstation and the network structure created a nomadic computing environment whereby the interface had the same functionality wherever an authorized user may have access to the web.

The project placed 5 network servers, 144 personal computers (95 purchased by the project), associated network routers and telecommunications equipment in 3 hospitals, 5 nursing homes, 3 health departments, 13 physician clinics, 1 mental health center, 1 home health agency, 1 ambulance service and 1 dentist office. A series of network devices, file servers and web servers housed at the MUHSC provided the connectivity to the Internet, RTEP workstation and other data services.

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