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Show that are extremely elaborate and correspondingly costly. For what purposes can telemedicine be used? Clinically, telemedicine can be used for a variety of health care purposes including (1) consultations, (2) transmission of scans, for example, by sending digitalized x-ray pictures from a remote rural clinic via electronic data transmission to a radiologist for an immediate reading, and (3) managing real-time medical routine and emergency procedures (e.g., accessing ER physicians in Denver or Salt Lake to assist local providers in managing trauma resulting from a multi-car pileup on 1-15). It can be used by any health care provider including physician assistants, nurse practitioners, family practitioners, and specialists. Indeed, for rural telemedicine systems to be effective, they must be used by a wide range of practitioners. Telecommunications technology also can be used for a variety of non-clinical health-related applications. Although this article focuses on clinical applications, telecommunications will profoundly revolutionize the way in which medical records are created, maintained and accessed, and how services are reimbursed. With the coming computerization of medical records and the subsequent billing for services, it will no longer be necessary to have a physical "file" on a patient. The medical records for a person can be located on one or more computer storage devices that are accessible, with proper security clearance, to any health care provider anywhere in the state, in the country, or even in the world. Such computerized records can contain information from every outpatient visit (to any provider - specialist or primary care), all pharmacy and laboratory results, all inpatient records, virtually every piece of recorded medical information. Thus, a provider can have a complete medical history of any person who requests service. Issues Bringing telemedicine to rural Utah is a process that spans complex technical and human issues. A limited selection of germane issues is discussed below. It is important to stress that there is no "one answer" involved in bringing telemedicine to rural Utah. Each community has unique problems and resources that will affect "the answer". Each community should weigh these issues and decide the best option. acquire a large portion of the given market. However, it can be detrimental to customers who must communicate with a wide range of outside institutions. Community Support: Telemedicine signals a change of "life as usual" in rural communities and may not be accepted (adopted) without strong leadership and community support (Kansas Telemedicine Policy Group - Vol III, 1993). Using telemedicine effectively requires a shift in how medicine and health care are practiced for both practitioners and patients. This shift will be successful only if both the professional community and the community at large understand and accept the changes. The community at large must also be educated about how the system will change the delivery of their health care. For example, patients must be willing to be "seen" by a specialist provider who may be hundreds of miles away. Having an intimate conversation about one's health (physical or mental) with a person on a TV screen is not the same experience as a face-to-face conversation. Some people may not be willing to do this, while others may like it better. For providers, effective use of telemedicine means utilizing new equipment and establishing new lines of communication with other providers. A telemedicine system will succeed only if adopted and used by the local health care providers. One common scenario nationally is that a hospital buys some telemedicine equipment and then finds that the physicians won't use it, or the equipment doesn't connect them to the right sites, or the equipment is too expensive to maintain. Some rural providers may hold the belief that "I got by fine without it, why do I need it now?" Some providers may have an antipathy toward anything viewed as "high tech" (some rural residents may hold the same views). Rural providers may not automatically see telemedicine as an improvement over the status quo and may need to be educated with regard to both its benefits and drawbacks. On the positive side, telemedicine can assist rural providers by providing a more interactive link with colleagues hundreds of miles away. Just as the telephone made it possible to talk with someone directly regardless of the distance, so telemedicine can mean that providers can directly consult, send x-rays, ultrasound, lab results, send still or moving photos of the patient to consulting specialists or colleagues who may be located far away. Telemedicine also holds the potential of enabling rural providers to educate urban providers about the realities of rural practice, since urban providers typically hold many prejudices and misconceptions about rural practice. Telemedicine technology could make it possible to hold a "grand rounds" of rural cases for urban practitioners. Because of their rural environments, rural providers may be the "experts" on conditions associated with rural working 96 TELEMEDICINE |