Teleconsultation Technology

As presented in Additional file 1: Table S1, all six of the teleconsultation projects studied at Site Y both during the first and second data collection periods utilized a basic modular teleconsultation workstation which HSC Y had designed and later licensed the manufacturing of to a major Japanese electronics company, because the specialty teleconsultation equipment available at the time was perceived as being both too complex and too costly for their requirements. Their teleconsultation workstation was put together with off-the-shelf components and included a full motion video codec (coder/decoder), an x-ray light box, and a one chip CCD camera which could be used to view the patient or tilted downward to view x-rays or documents. The workstation also included a video examination camera with a universal adapter to fit endoscopic applications, a high-powered xenon light source for general lighting purposes or for direct application to endoscopic devices, and an otoscope which could be directly attached to the exam camera and xenon light source. A unidirectional microphone was attached to the unit, and on top of the cabinet were two small high-resolution monitors, the larger showing the image being transmitted, and the smaller one showing the return transmission signal. A VCR was available to record and document teleconsultation sessions. The unit also had additional data ports and auxiliary audio/video inputs and outputs. During the second data collection period, a number of Site Y remote sites, including Y2 (medical specialties) and Y6 (school clinic), still utilized upgraded versions of that same workstation. The other Site Y remote sites utilized a newer generation of their basic teleconsultation workstation.

Nine of the remaining 11 projects studied utilized some variation of commercial off-the-shelf videoconferencing equipment (although multiple drug resistant tuberculosis teleconsultation Project X2 switched back to telephone, email, and facsimile during the second data collection period). At Site Z, no standard teleconsultation workstation was deployed throughout its network. Six of the eight teleconsultation projects studied at Site Z utilized videoconferencing equipment. The two other teleconsultation projects (Project HCV Z1 and Z3) utilized teleconferencing, although both were planning on migrating to videoconferencing in the near future.

At Site Z, both Projects HCV and DABC deployed basic Polycom videoconferencing equipment because the nature of their teleconsultation sessions required very limited technology capabilities. Such sessions generally involved a discussion between the various healthcare providers, although Project DABC sometimes included a patient being present. Project ECDD presented more difficult challenges from a technology perspective in that they had multiple, different teleconsultation workstation configurations and often used other project’s teleconsultation workstations as well. Further, as was standard practice in their field, Project ECDD also required equipment that could be used at the patient’s home. At the time of the second data collection period, they were on their fourth generation of teleconsultation workstations and had begun purchasing standard laptops equipped with HIPAA-compliant encryption software.

The teleconsultation projects studied in the first data collection period all utilized dedicated point-to-point telecommunication links—primarily because this was the only option available. These telecommunication links, usually either T1 lines or satellites, were very expensive (up to $3500 per month–although a number of states subsidized the cost) and thus unsustainable in the long run. At the time of the second data collection period, all the teleconsultation projects studied that were not utilizing teleconferencing as their main communication link were now using IP-based multipoint telecommunication networks. All of Site Y’s teleconsultation projects connected to the same educational and healthcare-related designated IP-based multipoint telecommunication network that had been implemented throughout the state. For Site Z, a statewide telecommunication network had not yet been fully deployed, and different teleconsultation projects utilized different telecommunication networks, or some combination thereof, to provide the connections between the HSC and the remote sites. These included a state-based educational network and networks belonging to different federal agencies.