Gail P Barker

Interests

Teaching

Business and Finance, Healthcare Administration, Telemedicine

Research

Use of contemporary technology as an educational tool and emerging business practices in telemedicine and telehealth.

Courses

Scholarly Contributions

Chapters

• Coe, K., Barker, G. P., & Palmer, C. T. (2011). Social Interaction and Technology: Cultural Competency and the Universality of Good Manners. In A Companion to Medical Anthropology(pp 443-458). Wiley-Blackwell. doi:10.1002/9781444395303.CH22

Journals/Publications

• Horton, M. B., Brady, C. J., Chiang, M. F., Crockett, C. H., Garg, S., Karth, P., Liu, Y., Newman, C. D., Rathi, S., Stebbins, K., Zimmer-galler, I., Silva, P. S., Sheth, V. S., Cavallerano, J. D., Barker, G. P., & Abramoff, M. D. (2020). Practice Guidelines for Ocular Telehealth-Diabetic Retinopathy, Third Edition.. Telemedicine journal and e-health : the official journal of the American Telemedicine Association, 26(4), 495-543. doi:10.1089/tmj.2020.0006
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  Contributors The following document and appendices represent the third edition of the Practice Guidelines for Ocular Telehealth-Diabetic Retinopathy. These guidelines were developed by the Diabetic Retinopathy Telehealth Practice Guidelines Working Group. This working group consisted of a large number of subject matter experts in clinical applications for telehealth in ophthalmology. The editorial committee consisted of Mark B. Horton, OD, MD, who served as working group chair and Christopher J. Brady, MD, MHS, and Jerry Cavallerano, OD, PhD, who served as cochairs. The writing committees were separated into seven different categories. They are as follows: 1.Clinical/operational: Jerry Cavallerano, OD, PhD (Chair), Gail Barker, PhD, MBA, Christopher J. Brady, MD, MHS, Yao Liu, MD, MS, Siddarth Rathi, MD, MBA, Veeral Sheth, MD, MBA, Paolo Silva, MD, and Ingrid Zimmer-Galler, MD. 2.Equipment: Veeral Sheth, MD (Chair), Mark B. Horton, OD, MD, Siddarth Rathi, MD, MBA, Paolo Silva, MD, and Kristen Stebbins, MSPH. 3.Quality assurance: Mark B. Horton, OD, MD (Chair), Seema Garg, MD, PhD, Yao Liu, MD, MS, and Ingrid Zimmer-Galler, MD. 4.Glaucoma: Yao Liu, MD, MS (Chair) and Siddarth Rathi, MD, MBA. 5.Retinopathy of prematurity: Christopher J. Brady, MD, MHS (Chair) and Ingrid Zimmer-Galler, MD. 6.Age-related macular degeneration: Christopher J. Brady, MD, MHS (Chair) and Ingrid Zimmer-Galler, MD. 7.Autonomous and computer assisted detection, classification and diagnosis of diabetic retinopathy: Michael Abramoff, MD, PhD (Chair), Michael F. Chiang, MD, and Paolo Silva, MD.
• Bracamonte, E., Krupinski, E. A., Briehl, M. M., Barker, G. P., Weinstein, R. S., Weinstein, R. S., Weinstein, J. B., Krupinski, E. A., Gibson, B. A., Briehl, M. M., Bracamonte, E., & Barker, G. P. (2018). A "Pathology Explanation Clinic (PEC)" for Patient-Centered Laboratory Medicine Test Results.. Academic pathology, 5, 2374289518756306. doi:10.1177/2374289518756306
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  This concept paper addresses communication issues arising between physicians and their patients. To facilitate the communication of essential diagnostic pathology information to patients, and address their questions and concerns, we propose that "Pathology Explanation Clinics" be created. The Pathology Explanation Clinics would provide a channel for direct communications between pathologists and patients. Pathologists would receive special training as "Certified Pathologist Navigators" in preparation for this role. The goal of Pathology Explanation Clinics would be to help fill gaps in communication of information contained in laboratory reports to patients, further explain its relevance, and improve patient understanding of the meaning of such information and its impact on their health and health-care choices. Effort would be made to ensure that Certified Pathologist Navigators work within the overall coordination of care by the health-care team.
• Weinstein, R. S., Waer, A. L., Briehl, M. M., Barker, G. P., Krupinski, E. A., Weinstein, R. S., Weinstein, J. B., Waer, A. L., Tomkins, J. M., Krupinski, E. A., Holtrust, A. L., Holcomb, M. J., Erps, K. A., Briehl, M. M., & Barker, G. P. (2017). Second Flexner Century: The Democratization of Medical Knowledge: Repurposing a General Pathology Course Into Multigrade-Level "Gateway" Courses.. Academic pathology, 4, 2374289517718872. doi:10.1177/2374289517718872
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  Starting in 1910, the "Flexner Revolution" in medical education catalyzed the transformation of the US medical education enterprise from a proprietary medical school dominated system into a university-based medical school system. In the 21st century, what we refer to as the "Second Flexner Century" shifts focus from the education of medical students to the education of the general population in the "4 health literacies." Compared with the remarkable success of the first Flexner Revolution, retrofitting medical science education into the US general population today, starting with K-12 students, is a more daunting task. The stakes are high. The emergence of the patient-centered medical home as a health-care delivery model and the revelation that medical errors are the third leading cause of adult deaths in the United States are drivers of population education reform. In this century, patients will be expected to assume far greater responsibility for their own health care as full members of health-care teams. For us, this process began in the run-up to the "Second Flexner Century" with the creation and testing of a general pathology course, repurposed as a series of "gateway" courses on mechanisms of diseases, suitable for introduction at multiple insertion points in the US education continuum. In this article, we describe nomenclature for these gateway courses and a "top-down" strategy for creating pathology coursework for nonmedical students. Finally, we list opportunities for academic pathology departments to engage in a national "Democratization of Medical Knowledge" initiative.
• Weinstein, R. S., Krupinski, E. A., Barker, G. P., Weinstein, R. S., Weinstein, J. B., Krupinski, E. A., Holtrust, A. L., Holcomb, M. J., Graham, A. R., Erps, K. A., & Barker, G. P. (2016). Flexner 3.0-Democratization of Medical Knowledge for the 21st Century: Teaching Medical Science Using K-12 General Pathology as a Gateway Course.. Academic pathology, 3, 2374289516636132. doi:10.1177/2374289516636132
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  A medical school general pathology course has been reformatted into a K-12 general pathology course. This new course has been implemented at a series of 7 to 12 grade levels and the student outcomes compared. Typically, topics covered mirrored those in a medical school general pathology course serving as an introduction to the mechanisms of diseases. Assessment of student performance was based on their score on a multiple-choice final examination modeled after an examination given to medical students. Two Tucson area schools, in a charter school network, participated in the study. Statistical analysis of examination performances showed that there were no significant differences as a function of school (F = 0.258, P = .6128), with students at school A having an average test scores of 87.03 (standard deviation = 8.99) and school B 86.00 (standard deviation = 8.18; F = 0.258, P = .6128). Analysis of variance was also conducted on the test scores as a function of gender and class grade. There were no significant differences as a function of gender (F = 0.608, P = .4382), with females having an average score of 87.18 (standard deviation = 7.24) and males 85.61 (standard deviation = 9.85). There were also no significant differences as a function of grade level (F = 0.627, P = .6003), with 7th graders having an average of 85.10 (standard deviation = 8.90), 8th graders 86.00 (standard deviation = 9.95), 9th graders 89.67 (standard deviation = 5.52), and 12th graders 86.90 (standard deviation = 7.52). The results demonstrated that middle and upper school students performed equally well in K-12 general pathology. Student course evaluations showed that the course met the student's expectations. One class voted K-12 general pathology their "elective course-of-the-year."
• Weinstein, R. S., Barker, G. P., Krupinski, E. A., Weinstein, R. S., Lopez, A. M., Krupinski, E. A., Joseph, B. A., Holcomb, M. J., Erps, K. A., & Barker, G. P. (2014). Telemedicine, telehealth, and mobile health applications that work: opportunities and barriers.. The American journal of medicine, 127(3), 183-7. doi:10.1016/j.amjmed.2013.09.032
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  There has been a spike in interest and use of telehealth, catalyzed recently by the anticipated implementation of the Affordable Care Act, which rewards efficiency in healthcare delivery. Advances in telehealth services are in many areas, including gap service coverage (eg, night-time radiology coverage), urgent services (eg, telestroke services and teleburn services), mandated services (eg, the delivery of health care services to prison inmates), and the proliferation of video-enabled multisite group chart rounds (eg, Extension for Community Healthcare Outcomes programs). Progress has been made in confronting traditional barriers to the proliferation of telehealth. Reimbursement by third-party payers has been addressed in 19 states that passed parity legislation to guarantee payment for telehealth services. Medicare lags behind Medicaid, in some states, in reimbursement. Interstate medical licensure rules remain problematic. Mobile health is currently undergoing explosive growth and could be a disruptive innovation that will change the face of healthcare in the future.
• Vega, S., Marciscano, I., Erps, K. A., Major, J., Lopez, A. M., Barker, G. P., Weinstein, R. S., Weinstein, R. S., & Holcomb, M. J. (2013). Testing a top-down strategy for establishing a sustainable telemedicine program in a developing country: the Arizona telemedicine program-US Army-Republic of Panama Initiative.. Telemedicine journal and e-health : the official journal of the American Telemedicine Association, 19(10), 746-53. doi:10.1089/tmj.2013.0025
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  Many developing countries have shown interest in embracing telemedicine and incorporating it into their healthcare systems. In 2000, the U.S. Army Yuma Proving Ground (YPG) initiated a program to assist the Republic of Panama in establishing a demonstration Panamanian rural telemedicine program. YPG engaged the Arizona Telemedicine Program (ATP) to participate in the development and implementation of the program..The ATP recommended adoption of a "top-down" strategy for creating the program. Early buy-in of the Panamanian Ministry of Health and academic leaders was regarded as critical to the achievement of long-term success..High-level meetings with the Minister of Health and the Rectors (i.e., Presidents) of the national universities gained early program support. A telemedicine demonstration project was established on a mountainous Indian reservation 230 miles west of Panama City. Today, three rural telemedicine clinics are linked to a regional Ministry of Health hospital for teleconsultations. Real-time bidirectional videoconferencing utilizes videophones connected over Internet protocol networks at a data rate of 768 kilobits per second to the San Felix Hospital. Telepediatrics, tele-obstetrics, telepulmonology, teledermatology, and tele-emergency medicine services became available. Telemedicine services were provided to the three sites for a total of 1,013 cases, with numbers of cases increasing each year. These three demonstration sites remained in operation after discontinuation of the U.S. involvement in September 2009 and serve as a model program for other telemedicine initiatives in Panama..Access to the assets of a partner-nation was invaluable in the establishment of the first model telemedicine demonstration program in Panama. After 3 years, the Panamanian Telemedicine and Telehealth Program (PTTP) became self-sufficient. The successful achievement of sustainability of the PTTP after disengagement by the United States fits the Latifi-Weinstein model for establishing telemedicine programs in developing countries.
• Barker, G. P., Krupinski, E. A., Bhattacharyya, A. K., Weinstein, R. S., Weinstein, R. S., Richter, L. C., Miller, A., Lopez, A. M., Lian, F., Krupinski, E. A., Kreykes, L. N., Henderson, J. T., Grasso, L. L., Graham, A. R., Bhattacharyya, A. K., & Barker, G. P. (2009). Virtual slide telepathology enables an innovative telehealth rapid breast care clinic.. Human pathology, 40(8), 1082-91. doi:10.1016/j.humpath.2009.04.005
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  An innovative telemedicine-enabled rapid breast care service is described that bundles telemammography, telepathology, and teleoncology services into a single day process. The service is called the UltraClinics Process. Because the core services are at 4 different physical locations, a challenge has been to obtain stat second opinion readouts on newly diagnosed breast cancer cases. To provide same day quality assurance rereview of breast surgical pathology cases, a DMetrix DX-40 ultrarapid virtual slide scanner (DMetrix Inc, Tucson, AZ) was installed at the participating laboratory. Glass slides of breast cancer and breast hyperplasia cases were scanned the same day the slides were produced by the University Physicians Healthcare Hospital histology laboratory. Virtual slide telepathology was used for stat quality assurance readouts at University Medical Center, 6 miles away. There was complete concurrence with the primary diagnosis in 139 (90.3%) of cases. There were 4 (2.3%) major discrepancies, which would have resulted in a different therapy and 3 (1.9%) minor discrepancies. Three cases (1.9%) were deferred for immunohistochemistry. In 2 cases (1.3%), the case was deferred for examination of the glass slides by the reviewing pathologists at University Medical Center. We conclude that the virtual slide telepathology quality assurance program found a small number of significant diagnostic discrepancies. The virtual slide telepathology program service increased the job satisfaction of subspecialty pathologists without special training in breast pathology, assigned to cover the general surgical pathology service at a small satellite university hospital.
• Bhattacharyya, A. K., Barker, G. P., Weinstein, R. S., Weinstein, R. S., Scott, K. M., Richter, L. C., Lopez, A. M., Lian, F., Henderson, J. T., Grasso, L. L., Graham, A. R., Chiang, S., Carpenter, J. B., Bhattacharyya, A. K., & Barker, G. P. (2009). Virtual slide telepathology for an academic teaching hospital surgical pathology quality assurance program.. Human pathology, 40(8), 1129-36. doi:10.1016/j.humpath.2009.04.008
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  Virtual slide telepathology is an important potential tool for providing re-review of surgical pathology cases as part of a quality assurance program. The University of Arizona pathology faculty has implemented a quality assurance program between 2 university hospitals located 6 miles apart. The flagship hospital, University Medical Center (UMC), in Tucson, AZ, handles approximately 20 000 surgical pathology specimens per year. University Physicians Healthcare Hospital (UPHH) at Kino Campus has one tenth the volume of surgical pathology cases. Whereas UMC is staffed by 10 surgical pathologists, UPHH is staffed daily by a single part-time pathologist on a rotating basis. To provide same-day quality assurance re-reviews of cases, a DMetrix DX-40 ultrarapid virtual slide scanner (DMetrix, Inc, Tucson, AZ) was installed at the UPHH in 2005. Since then, glass slides of new cases of cancer and other difficult cases have been scanned the same day the slides are produced by the UPHH histology laboratory. The pathologist at UPHH generates a provisional written report based on light microscopic examination of the glass slides. At 2:00 pm each day, completed cases from UPHH are re-reviewed by staff pathologists, pathology residents, and medical students at the UMC using the DMetrix Iris virtual slide viewer. The virtual slides are viewed on a 50-in plasma monitor. Results are communicated with the UPHH laboratory by fax. We have analyzed the results of the first 329 consecutive quality assurance cases. There was complete concordance with the original UPHH diagnosis in 302 (91.8%) cases. There were 5 (1.5%) major discrepancies, which would have resulted in different therapy and/or management, and 10 (3.0%) minor discrepancies. In 6 cases (1.8%), the diagnosis was deferred for examination of the glass slides by the reviewing pathologists at UMC, and the diagnosis of another 6 (1.8%) cases were deferred pending additional testing, usually immunohistochemistry. Thus, the quality assurance program found a small number of significant diagnostic discrepancies. We also found that implementation of a virtual slide telepathology quality assurance service improved the job satisfaction of academic subspecialty pathologists assigned to cover on-site surgical pathology services at a small, affiliated university hospital on a rotating part-time basis. These findings should be applicable to some community hospital group practices as well.
• Weinstein, R. S., Barker, G. P., Krupinski, E. A., Bhattacharyya, A. K., Yagi, Y., Weinstein, R. S., Richter, L. C., Lopez, A. M., Krupinski, E. A., Graham, A. R., Gilbertson, J. R., Erps, K. A., Bhattacharyya, A. K., & Barker, G. P. (2009). Overview of telepathology, virtual microscopy, and whole slide imaging: prospects for the future.. Human pathology, 40(8), 1057-69. doi:10.1016/j.humpath.2009.04.006
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  Telepathology, the practice of pathology at a long distance, has advanced continuously since 1986. Today, fourth-generation telepathology systems, so-called virtual slide telepathology systems, are being used for education applications. Both conventional and innovative surgical pathology diagnostic services are being designed and implemented as well. The technology has been commercialized by more than 30 companies in Asia, the United States, and Europe. Early adopters of telepathology have been laboratories with special challenges in providing anatomic pathology services, ranging from the need to provide anatomic pathology services at great distances to the use of the technology to increase efficiency of services between hospitals less than a mile apart. As to what often happens in medicine, early adopters of new technologies are professionals who create model programs that are successful and then stimulate the creation of infrastructure (ie, reimbursement, telecommunications, information technologies, and so on) that forms the platforms for entry of later, mainstream, adopters. The trend at medical schools, in the United States, is to go entirely digital for their pathology courses, discarding their student light microscopes, and building virtual slide laboratories. This may create a generation of pathology trainees who prefer digital pathology imaging over the traditional hands-on light microscopy. The creation of standards for virtual slide telepathology is early in its development but accelerating. The field of telepathology has now reached a tipping point at which major corporations now investing in the technology will insist that standards be created for pathology digital imaging as a value added business proposition. A key to success in teleradiology, already a growth industry, has been the implementation of standards for digital radiology imaging. Telepathology is already the enabling technology for new, innovative laboratory services. Examples include STAT QA surgical pathology second opinions at a distance and a telehealth-enabled rapid breast care service. The innovative bundling of telemammography, telepathology, and teleoncology services may represent a new paradigm in breast care that helps address the serious issue of fragmentation of breast cancer care in the United States and elsewhere. Legal and regulatory issues in telepathology are being addressed and are regarded as a potential catalyst for the next wave of telepathology advances, applications, and implementations.
• Weinstein, R. S., Barker, G. P., Krupinski, E. A., Bartels, P. H., Bhattacharyya, A. K., Weinstein, R. S., Scott, K. M., Richter, L. C., Mcneely, R. A., Lopez, A. M., Krupinski, E. A., Holcomb, M. J., Descour, M. R., Bhattacharyya, A. K., Beinar, S. J., Bartels, P. H., & Barker, G. P. (2007). The innovative bundling of teleradiology, telepathology, and teleoncology services. Ibm Systems Journal, 46(1), 69-84. doi:10.1147/sj.461.0069
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  Teleradiolosy, telepathology, and teleoncology are important applications of telemedicine. Recent advances in these fields include a preponderance of radiology PACS (Picture Archiving and Communications System) users, the implementation of around-the-clock teleradiology services at many hospitals, and the invention of the first ultrarapid whole-slide digital scanner based on the array microscope. These advances have led to the development of a new health-care-delivery clinical pathway called the ultrarapid breast care process (URBC), which has been commercialized as the UltraClinics® process. This process bundles telemammography, telepathology, and teleoncology services and has reduced the time it takes for a woman to obtain diagnostic and therapeutic breast-care planning services from several weeks to a single day. This paper describes the UltraClinics process in detail and presents the vision of a network of same-day telemedicine-enabled UltraClinics facilities, staffed by a virtual group practice of teleradiologists, telepathologists, and teleoncologists.
• Weinstein, R. S., Barker, G. P., Krupinski, E. A., Weinstein, R. S., Skinner, T., Mcneely, R. A., Major, J., Lopez, A. M., Krupinski, E. A., Holcomb, M. J., Beinar, S. J., & Barker, G. P. (2007). Arizona Telemedicine Program Interprofessional Learning Center: facility design and curriculum development.. Journal of interprofessional care, 21 Suppl 2(sup2), 51-63. doi:10.1080/13561820701349321
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  The Institute for Advanced Telemedicine and Telehealth (i.e., T-Health Institute), a division of the state-wide Arizona Telemedicine Program (ATP), specializes in the creation of innovative health care education programs. This paper describes a first-of-a-kind video amphitheater specifically designed to promote communication within heterogeneous student groups training in the various health care professions. The amphitheater has an audio-video system that facilitates the assembly of ad hoc "in-the-room" electronic interdisciplinary student groups. Off-site faculty members and students can be inserted into groups by video conferencing. When fully implemented, every student will have a personal video camera trained on them, a head phone/microphone, and a personal voice channel. A command and control system will manage the video inputs of the individual participant's head-and-shoulder video images. An audio mixer will manage the separate voice channels of the individual participants and mix them into individual group-specific voice channels for use by the groups' participants. The audio-video system facilitates the easy reconfiguration of the interprofessional electronic groups, viewed on the video wall, without the individual participants in the electronic groups leaving their seats. The amphitheater will serve as a classroom as well as a unique education research laboratory.
• Barker, G. P., Krupinski, E. A., Weinstein, R. S., Bhattacharyya, A. K., Weinstein, R. S., Venker, C. C., Scott, K. M., Richter, L. C., Lopez, A. M., Krupinski, E. A., Howerter, A., Descour, M. R., Bhattacharyya, A. K., & Barker, G. P. (2006). Demonstration of an expedited breast care (EBC) clinic. Journal of Clinical Oncology, 24(18_suppl), 16023-16023. doi:10.1200/jco.2006.24.18_suppl.16023
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  16023 Background: Women report waiting for a breast biopsy result as a time of psychological distress. Waiting also delays entry into definitive oncology care, and patients in underserved communities may be lost to follow up. In this proof-of-concept demonstration, an Expedited Breast Care (EBC) clinic was developed to give patients the opportunity to receive same-day biopsy results. Methods: Patients requiring core breast biopsy at a community hospital were approached sequentially to participate. Following surgical biopsy, tissue underwent ultra-rapid fixation and processing. After paraffin sections were prepared and stained, the glass histopathology slides were imaged with a virtual slide scanner. Digital images were stored on a server and viewed on the Internet by a telepathologist at a tertiary care center. Light microscopy review was concurrently performed as the gold standard. After telepathology review and light microscopy confirmation, patients presented to the telemedicine suite to receive biopsy...
• Barker, G. P., Krupinski, E. A., Mcneely, R. A., Holcomb, M. J., Lopez, A. M., & Weinstein, R. S. (2005). The Arizona Telemedicine Program business model. Journal of Telemedicine and Telecare, 11(8), 397-402. doi:10.1258/135763305775013536
• Barker, G. P., Krupinski, E. A., Weinstein, R. S., Weinstein, R. S., Mcneely, R. A., Lopez, A. M., Krupinski, E. A., Holcomb, M. J., & Barker, G. P. (2005). The Arizona Telemedicine Program business model.. Journal of telemedicine and telecare, 11(8), 397-402. doi:10.1177/1357633x0501100804
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  The Arizona Telemedicine Program (ATP) was established in 1996 when state funding was provided to implement eight telemedicine sites. Since then the ATP has expanded to connect 55 health-care organizations through a membership programme formalized through legal contracts. The ATP's membership model is based on an application service provider (ASP) concept, whereby organizations can share services at lower cost; that is, the ATP acts as a broker for services. The membership fee schedule is flexible, allowing clients to purchase only those services desired. An annual membership fee is paid by every user, based on the services requested. The membership programme income has provided a steady revenue stream for the ATP. The membership-derived revenue represented 30% of the ATP's 2.6 million dollars total income during fiscal year 2003/04.
• Barker, G. P., Krupinski, E. A., Weinstein, R. S., Weinstein, R. S., Schellenberg, B., Krupinski, E. A., & Barker, G. P. (2004). Expense comparison of a telemedicine practice versus a traditional clinical practice.. Telemedicine journal and e-health : the official journal of the American Telemedicine Association, 10(3), 376-80. doi:10.1089/tmj.2004.10.376
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  This paper compares the expenses of a telemedicine program to those of a traditional clinical practice using data from two fiscal years (FY) 1998/1999 and 2000/2001. As part of that evaluation, we compared expenses of the University of Arizona's clinical practice group, the University Physicians Incorporated (UPI), to those of the Arizona Telemedicine Program (ATP) practice. For this study, we used the reporting categories published in the year-end UPI financial statement. These categories included clinical services, administration, equipment depreciation, and overhead. Results showed that clinical service expenses and administrative expenses for FY 2000/2001 were higher in the traditional UPI practice, whereas equipment depreciation and overhead expenses are higher in the telemedicine practice. This differs somewhat from FY 1998/1999, where clinical expenses and overhead were higher in the UPI practice and administration and equipment depreciation were higher in the telemedicine practice. We will discuss the relevance of these results and the critical factors that contribute to these differences.
• Krupinski, E. A., Weinstein, R. S., Barker, G. P., Weinstein, R. S., Levine, N., Krupinski, E. A., Engstrom, M., & Barker, G. P. (2004). The challenges of following patients and assessing outcomes in teledermatology.. Journal of telemedicine and telecare, 10(1), 21-4. doi:10.1258/135763304322764149
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  We retrospectively reviewed the follow-up and outcomes of 50 store-and-forward teledermatology patients, and compared the findings with those from a control group of 50 patients who had been seen in person. Patient records were examined for a six-month period following the initial referral to a dermatologist. Variables examined included medical records from the referral, evidence of actions taken (e.g. biopsy), evidence of follow-up visits, and what (if any) clinical outcomes were noted. There were few differences between the teledermatology and in-person groups. The main difference was whether there was any report in the record that the referring clinician took some action based on the consultation with the specialist: there were more reports of action being taken in the teledermatology group than in the in-person group. Reports of outcomes were found in only 6% and 8% of the records of the teledermatology and in-person groups, respectively. The challenges of assessing outcomes in teledermatology for rural patients include patient loss to follow-up, lack of information in the patient records and low rates of patient return to the referring clinician for follow-up.
• Krupinski, E. A., Weinstein, R. S., Barker, G. P., Weinstein, R. S., Lopez, A. M., Krupinski, E. A., & Barker, G. P. (2004). An analysis of unsuccessful teleconsultations.. Journal of telemedicine and telecare, 10(1), 6-10. doi:10.1258/135763304322764112
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  Over six years, 4317 teleconsultations were scheduled in the Arizona Telemedicine Program. A total of 402 scheduled teleconsultations (9.3%) did not take place. A review showed that 254 were cancelled but eventually took place (5.9%), while 148 never took place (3.4%). The cost of a teleconsultation to the service provider was, at minimum, 228 US dollars. Telepsychiatry accounted for all the missed consultations that eventually took place, and 92% of these were from three of the six sites referring telepsychiatry patients. Pain management (23%) and psychiatry (21%) accounted for the largest proportions of teleconsultations that never took place. Telepsychiatry cases accounted for 71% of all unsuccessful consultations and accounted for only 34% of successful teleconsultations during the same period. Most missed teleconsultations had been scheduled as realtime sessions (84%). The most common reason for unsuccessful teleconsultations was that the patient did not attend (26%), followed by the patient having to be seen in person (17%). Although all referring sites had unsuccessful cases, certain sites accounted for more than others. These were sites that scheduled more telepsychiatry consultations than the others. The proportion of unsuccessful cases per site ranged from 4% to 17% of the total number of scheduled teleconsultations.
• Krupinski, E. A., Weinstein, R. S., Barker, G. P., Weinstein, R. S., Lyman, T., Lopez, A. M., Krupinski, E. A., & Barker, G. P. (2004). Continuing education via telemedicine: analysis of reasons for attending or not attending.. Telemedicine journal and e-health : the official journal of the American Telemedicine Association, 10(3), 403-9. doi:10.1089/tmj.2004.10.403
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  This study analyzed factors that influence the decision to attend or not attend tele-education broadcasts via a telemedicine network for continuing education (CE) credits. A questionnaire was developed and sent to all participating sites on our telemedicine network that have attended CE broadcasts. The majority of respondents attend specific types of broadcasts, receiving less than 25% of their CE credits from the tele-education broadcasts. Factors most influencing the decision to attend a broadcast include interest in the topic and perceived utility of the information. The most common reason influencing the decision not to attend is an explicit preference for attending conferences. Tele-education broadcasts may supplement other CE activities but may not replace them. The attraction of attending conferences in person is very high and may be especially so for health-care professionals in rural environments.
• Krupinski, E. A., Weinstein, R. S., Barker, G. P., Weinstein, R. S., Mcneill, K. M., Krupinski, E. A., & Barker, G. P. (2004). Clinical encounters costing for telemedicine services.. Telemedicine journal and e-health : the official journal of the American Telemedicine Association, 10(3), 381-8. doi:10.1089/tmj.2004.10.381
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  The Arizona Telemedicine Program (ATP) has developed a costing model that includes a number of factors contributing to the cost of providing services via telemedicine and generates a per-encounter cost. We first developed the model in 1999 and in this paper used it to analyze clinical services for the fiscal year 2000/2001. We evaluated the calculated weighted cost for providing those services via telemedicine as compared to the cost of providing those services "face-to-face." The cost of providing services via telemedicine was found to be lower when a patient had to travel 127.5 miles or more to receive clinical services. Our study provides analysis of the factors, their contribution to costs, as well as some factors, which are pertinent, but are more problematic to calculate. In this paper, we discuss the relevance of these results as they relate to telemedicine programs and a possible means to reduce costs even further.
• Weinstein, R. S., Krupinski, E. A., Bhattacharyya, A. K., Bartels, P. H., Rennels, M. A., Barker, G. P., Zhou, P., Wyant, J. C., Williams, B. H., Weinstein, R. S., Scott, K. M., Russum, W. C., Richter, L., Rennels, M. A., Olszak, A. G., Liang, C., Krupinski, E. A., Graham, A. R., Goodall, J. F., , Descour, M. R., et al. (2004). An array microscope for ultrarapid virtual slide processing and telepathology. Design, fabrication, and validation study.. Human pathology, 35(11), 1303-14. doi:10.1016/j.humpath.2004.09.002
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  This paper describes the design and fabrication of a novel array microscope for the first ultrarapid virtual slide processor (DMetrix DX-40 digital slide scanner). The array microscope optics consists of a stack of three 80-element 10 x 8-lenslet arrays, constituting a "lenslet array ensemble." The lenslet array ensemble is positioned over a glass slide. Uniquely shaped lenses in each of the lenslet arrays, arranged perpendicular to the glass slide constitute a single "miniaturized microscope." A high-pixel-density image sensor is attached to the top of the lenslet array ensemble. In operation, the lenslet array ensemble is transported by a motorized mechanism relative to the long axis of a glass slide. Each of the 80 miniaturized microscopes has a lateral field of view of 250 microns. The microscopes of each row of the array are offset from the microscopes in other rows. Scanning a glass slide with the array microscope produces seamless two-dimensional image data of the entire slide, that is, a virtual slide. The optical system has a numerical aperture of N.A.= 0.65, scans slides at a rate of 3 mm per second, and accrues up to 3,000 images per second from each of the 80 miniaturized microscopes. In the ultrarapid virtual slide processing cycle, the time for image acquisition takes 58 seconds for a 2.25 cm2 tissue section. An automatic slide loader enables the scanner to process up to 40 slides per hour without operator intervention. Slide scanning and image processing are done concurrently so that post-scan processing is eliminated. A virtual slide can be viewed over the Internet immediately after the scanning is complete. A validation study compared the diagnostic accuracy of pathologist case readers using array microscopy (with images viewed as virtual slides) and conventional light microscopy. Four senior pathologists diagnosed 30 breast surgical pathology cases each using both imaging modes, but on separate occasions. Of 120 case reads by array microscopy, there were 3 incorrect diagnoses, all of which were made on difficult cases with equivocal diagnoses by light microscopy. There was a strong correlation between array microscopy vs. "truth" diagnoses based on surgical pathology reports. The kappa statistic for the array microscopy vs. truth was 0.96, which is highly significant (z=10.33, p 0.05). Array microscopy and light microscopy did not differ significantly with respect to the number/percent of correct decisions rendered (t=0.552, p=0.6376) or equivocal decisions rendered (t=2.449, p=0.0917). Pathologists rated 95.8% of array microscopy virtual slide images as good or excellent. None were rated as poor. The mean viewing time for a DMetrix virtual slide was 1.16 minutes. The DMetrix virtual slide processor has been found to reduce the virtual slide processing cycle more than 10 fold, as compared with other virtual slide systems reported to date. The virtual slide images are of high quality and suitable for diagnostic pathology, second opinions, expert opinions, clinical trials, education, and research.
• Krupinski, E. A., Barker, G. P., Weinstein, R. S., Weinstein, R. S., Lopez, A. M., Krupinski, E. A., Hughes, A. M., & Barker, G. P. (2003). Fluctuations in telemedicine case volume: correlation with personnel turnover rates.. Telemedicine journal and e-health : the official journal of the American Telemedicine Association, 9(4), 369-73. doi:10.1089/153056203772744699
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  Statistical process control (SPC) techniques were used to analyze 5 years worth of telemedicine case volume data from seven remote sites in order to characterize how much fluctuation occurred over time for each site and whether the fluctuation remained within prescribed limits. The points at which the fluctuations were considered beyond the prescribed limits were correlated with the turnover rate in key personnel (e.g., the Medical Director). Though no causal relationship can be implied, sites with higher turnover rates tended to fluctuate more. The analyses suggest that SPC may be a useful tool for analyzing trends in telemedicine consultation volume fluctuations over time and, therefore, may be useful for program management and allocation of personnel resources. It can also be used in the long run to determine when and why fluctuations occur and whether the causes of fluctuations need to be addressed.
• Weinstein, R. S., Krupinski, E. A., Barker, G. P., Weinstein, R. S., Rodriguez, G., Lopez, A. M., Levine, N., Krupinski, E. A., Engstrom, M., & Barker, G. P. (2002). Telemedicine versus in-person dermatology referrals: an analysis of case complexity.. Telemedicine journal and e-health : the official journal of the American Telemedicine Association, 8(2), 143-7. doi:10.1089/15305620260008075
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  The goal of this study was to determine whether teledermatology referrals differ significantly from in-person referrals with respect to case complexity and diagnosis of cases referred. Teledermatology cases were compared to in-person cases seen by the same university dermatologist who also reviews the teledermatology cases. These were also compared with in-person cases evaluated by a different dermatologist at local clinics using traditional referral patterns. Study parameters included Current Procedural Terminology (CPT) codes as a measure of case complexity, International Classification of Disease (ICD) codes as a measure of case types, and time from referral to actual consultation. The most common CPT codes used for teledermatology were 99241 and 99242 with no significant differences in the frequency of assigned CPT codes for teledermatology versus in-person consultation. An analysis of the diagnostic codes revealed no significant differences between the types of cases referred to telemedicine and those referred for in-person consultation. Time between referral and actual encounter with the dermatologist was significantly shorter via telemedicine than either local or university clinic in-person visits.
• Krupinski, E. A., Barker, G. P., Weinstein, R. S., Weinstein, R. S., Lopez, A. M., Krupinski, E. A., Beinar, S., & Barker, G. P. (2001). Fluctuations in service loads in an established telemedicine program.. Telemedicine journal and e-health : the official journal of the American Telemedicine Association, 7(1), 27-31. doi:10.1089/153056201300093859
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  The goal of this investigation was to determine if there were identifiable patterns in the volume and types of teleconsults provided by an established telemedicine program over an extended period of time. Data from over 3 years of providing telemedicine consults within a university-based telemedicine programs were analyzed to identify trends and points of significant change in service provision. Teleconsult volume over a 40-month period was best fit by a logarithmic transformation of the regression curve that is characteristic of slow but steady growth. Consults have been provided in 53 subspecialties, with an average of 12 different subspecialties each month. Number of subspecialties per month was best fit by a sixth-order polynomial. Teleconsult volume has varied on a monthly basis, but overall volume has increased over time. This program has maintained its initial goal of being a multispecialty provider. Analyzing telemedicine consult data over extended periods of time is especially useful for long-term program evaluation and development of a successful business plan.
• Krupinski, E. A., Weinstein, R. S., Barker, G. P., Weinstein, R. S., Laursen, T., Krupinski, E. A., Erps, K. A., & Barker, G. P. (2001). Pay per view: the Arizona telemedicine program's billing results.. Telemedicine journal and e-health : the official journal of the American Telemedicine Association, 7(4), 287-91. doi:10.1089/15305620152814692
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  This paper describes the results of a study of telemedicine billing and collection activities of the Arizona Telemedicine Program. The program began billing for clinical services in January 1999, one and one-half years after commencement of clinical services. In preparation, a letter was sent to all third-party payers in the state informing them of our intention to bill starting in January 1999. From January 1999–June 2000, 1135 nonradiology cases have been billed. An analysis of the telemedicine billing and collection activities revealed that 47 individual plans were invoiced. The payer mix was Private Insurance 29%, Medicaid/State Programs 24%, Indian Health Service 17%, Medicare/Champus 13%, Self Pay 9%, and Department of Corrections 8%. To date, a total of $41,258 was billed to private payers. Of this, $17,607 was collected, which represents a 42.7% gross collection rate (GCR.) This compares with the university's physician group practice GCR of 48.3%. In the following fiscal year, 1999–2000, the GCR i...

Proceedings Publications

• Mcneill, K. M., Mcelroy, J., & Barker, G. P. (2001). Experience using an ASP model to expand a state-initiated telemedicine program. In International Congress Series, 1230, 824-829.
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  Abstract The Arizona Telemedicine Program began in 1996 as a state-initiated program to create the technical infrastructure for the statewide deployment of telemedicine. An important goal was to develop a business model to move toward self-sustainability and enable additional healthcare organizations to participate without increased state funding. In Arizona, small, geographically isolated communities are under-served both in terms of specialty medical services and telecommunications, while a few urban areas concentrate on medical resources and specialty services. There are traditional geographically based referral patterns that would have to be supported in order for telemedicine to be successful and the Program sought to create a model for expanding telemedicine as a “peer” network in place of the traditional “hub-and-spoke” model common to telemedicine at that time. In 1997, the Program developed a membership model focused on the core telemedicine network services. Any member of the network can interact with any other member of the network for clinical telemedicine services and medical education programming. Professional clinical services among members are established using separate agreements that are layered upon, and independent of, the network membership contract. Using this membership model, the telemedicine network in Arizona has grown from the initial eight sites funded by the state to more than 22 sites. Cost recovery from the memberships and other centralized cost recovery enabled by the model now offsets 45% of the total cost of operating the statewide infrastructure. This Application Service Provider (ASP)-based membership model for telemedicine network services has worked extremely well for Arizona.