Appendix 5: The basic design and workflow of the initial telemedicine program

The tertiary academic referral center will offer the following services to the referring center (includes rural medical centers, clinics, hospitals, urgent care centers, etc.) using the following technologies; store-and-forward services, two-way videoconferencing, home telemonitoring (initial limited device menu that can easily expand with -experience and time), population management, secure messaging (referring and referral center, referral center and patient), and when necessary the choice for in-person office visits. 1. The patient has been seen in a rural medical clinic at substantial distance from the referral center. 2. The local physician has provided primary care for the diabetes that remains a problem with control of glucose and subsequent secondary complications. 3. The patient needs subspecialty care and struggles with the distance to the academic center. 4. The academic tertiary center in collaboration with the rural medical facility can offer the patient subspecialty care in the local facility. 5. The local facility will have a video conferencing capability with proper exam equipment and local technical skill (using a nurse practitioner and or medical assistant). 6. The patient will be roomed and appropriate vital signs taken (and if available entered into the referral centers EMR [most recommended] and manage the equipment during the electronic visit with the specialist.

7. The specialist, located at the academic center, can participate in a real-time electronic visit and synchronously communicate with the patient. Thist type of encounter can be used as necessary. 8. The specialist can also use local electronic tools (EMR, PHR, etc) to offer asynchronous electronic visits. 9. The patient may use a personal health record via internet and communicate securely with the subspecialist during an e-visit from home. 10. The subspecialist replies to the secure message and completes the visit without seeing the patient. 11. The patient has the opportunity to use smart phone or camera to transmit data for skin lesions if needed. 12. The patients glucose is not controlled, a portable glucometer is used to transmit glucose values securely to the subspecialist. 13. If values are unacceptable, the specialist (and support-staff) can be alerted immediately if necessary. 14. Summaries of care are transmitted to the referring physician as needed or telephonic follow-up enhances communication with the patient and referring medical professional(s). 15. Using the EMRs alert functionality, the following visio demonstrates how the home glucometer is effectively utilized.

Algorithm

a.