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Executive SummaryThis document reflects the strongly held views and perspective of a diverse group of healthcare academicians, researchers, providers, and industry representatives from across the country who share a belief in the necessity of healthcare reform and the centrality of telemedicineor information technology-enhanced healthcare-in that reform.The need for reform stems from long-standing problems in our health system, and the central role of telemedicine derives from an ever-expanding body of research and experience that attests to its merit in addressing these problems. Despite the fact that the United States spends more on healthcare than any other country, both in absolute numbers and on a per capita basis, the health status of Americans ranks relatively low when compared with that of people in other developed nations. Moreover, the general discrepancy between expenditures and health status indicators in the United States masks significant differentials among segments of the population, based on socio-economic, geographic, cultural, ethnic, and other factors. Hence, we continue to suffer from inequities in access to healthcare, inefficiencies in the delivery of care, escalating costs, and the prevalence of adverse lifestyles that exacerbate these problems.Much attention has been devoted to the utility of the electronic health records (EHRs) as a means to improving the healthcare system. Yet, despite its potential benefits, the EHR represents only a partial solution to the problems we face. A broader focus on telemedicine (also frequently referred to as telehealth or e-health) that incorporates EHRs is a more prudent and effective approach. We believe that an exclusive concern with developing system-wide EHRs, while laudable and potentially valuable in improving one sector in healthcare delivery, would ultimately increase the cost of care without contributing to necessary changes in the rest of the system. National Telemedicine Initiatives: Essential to Healthcare Reform © MARY ANN LIEBERT, INC. • VOL. 15 NO. 6 • JULY/AUGUST 2009 TELEMEDICINE and e-HEALTH 601 NATIONAL TELEMEDICINE INITIATIVES Telemedicine technology embodies the electronic acquisition, processing, dissemination, storage, retrieval, and exchange of information for the purpose of promoting health, preventing disease, treating the sick, managing chronic illness, rehabilitating the disabled, and protecting public health and safety. Telemedicine systems consist of collaborative health networks, facilities, and organizations dedicated to these objectives. Over the past several decades, telemedicine systems have demonstrated the capacity to do the following: • Improve access to all levels (primary, secondary, and tertiary) of healthcare for a wide range of conditions-including, but not limited to, heart and cerebrovascular disease, endocrine disorders such as diabetes, cancer, psychiatric disorders, and trauma; as well as services such as radiology, pathology, and rehabilitation. • Promote patient-centered care at lower cost and in local env...

From January 1 to September 30, 1974, we examined 1056 of 5266 subjects (20.1%) who had received therapeutic irradiation primarily for infections and inflammatory disease of the upper respiratory tract at our institution during the 1940's and 1950's. The tonsillar and nasopharyngeal region was the treatment site in 85% of those examined. Palpable nodular thyroid disease was found in 16.5%, and nonpalpable lesions were detected by 99m Tc pertechnetate thyroid imaging in an additional 10.7%, for a prevalence of nodular disease of 27.2%. Operation on 71% with nodular disease revealed thyroid cancer in 33% (60 of 182). Preliminary analysis for potential risk factors suggests a correlation between radiation exposure and the presence of thyroid nodules (P less than 0.001). These findings indicate that nodular thyroid disease, both benign and malignant, continues as a major health problem for at least 35 years in exposed subjects.

In terms of family attitudes and individual care, telemedicine is an acceptable means of delivering specific pediatric subspecialty consultation services to children with special health care needs, living in rural areas distant to tertiary centers. Telemedicine is more likely to be successful as part of an integrated health services delivery than when it is the sole mode used for delivery of care.

Objective. To examine adoption of telehealth in a rural public health district and to explain how the innovation became sustainable. Study Setting. Longitudinal, qualitative study (1988Longitudinal, qualitative study ( -2008 of the largest public health district in Georgia. Study Design. Case study design provided deep insights into the innovation's social dynamics. Punctuated equilibrium theory helped present and make sense of the process. We identified antecedent conditions and outcomes, and we distinguished between episodes and encounters based on the disruptive effects of events. Data Collection. Twenty-five semistructured interviews with 19 decision makers and professionals, direct observations, published papers, grant proposals, technical specifications, and other written materials. Principal Findings. Strong collaboration within the district, with local community, and with external partners energized the process. Well-functioning outreach clinics made telehealth desirable. Local champions cultivated participation and generative capability, and overcame barriers through opportunistic exploitation of technological and financial options. Telehealth usage fluctuated between medical and administrative operations in response to internal needs and contextual dynamics. External agencies provided initial funding and supported later expansion. Conclusions. Extensive internal and external collaboration, and a combination of technology push and opportunistic exploitation, can enable sustainable rural telehealth innovation.