A nice reminder why I did it in the first place, but where is the patient?

On September 8 it was 4 years ago that I founded ICMCC, supported by my first, visionary board members. Medical and care ICT was something I had stumbled upon and knew little about in those days.
After the first 2 years, September 2006, we had a final definition of the word compunetics, thus being the only global organisation dealing with patient-related ICT. Unfortunately, by that time my mentor and ICMCC co-founder Swamy Laxminarayan had passed away and I was diagnosed with a very aggressive form of Non-Hodgkin.
During the past 2 years, ICMCC has developped itself. Our newspage, with an average of 6,000 unique visitors per month, has become an important source of information. Our Record Access Portal is still the only of it’s kind on the subject. Compunetics as a discipline is slowly entering other areas (e.g. behavioural compunetics), our annual conferences have become important meeting points, our proceedings are considered outstanding publications.

However, when you go through the emotional roller coaster that seems to be more or less obligatory after major treatment for a major kind of cancer, it is nice to read an article that reminds you of why you started it all in the first place. Prescription for change, from professor Amar Gupta, published in the Wall Street Journal on 20 October 2008, is such an article.

“In the future, there will be three often overlapping modes of delivering health-care services: services performed in person by humans, services that can be performed by people at a remote location, and services performed by computers without direct human involvement. Offshore outsourcing in combination with a 24-hour work cycle will be appropriate when certain conditions are met — mainly, if the information involved in the task can be digitized, and if workers at different sites can do their jobs independently from one another.”

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Sharing and Caring, PHSCG Conference, 1 July 2008, Chesford Grange, UK

More details on the conference.

View the speech.

Ladies and Gentlemen,

First of all I would like to thank the organisation and Dr. Amir Hannan for inviting me to address this conference.
Secondly I apologize for not being here myself.

This conference deals with sharing and caring and I was specifically asked to highlight the international aspects.

ICMCC introduced 4 years ago the word Compunetics and we were the first to link it to healthcare. Compunetics defines the social, societal and ethical aspects of the use of computing and networking. So we already realised the importance of these issues before Web2.0 and Health2.0 appeared on the horizon. The use of the word compunetics directly and urgently implicates the patient as one of the main focussing points of our foundation. More specifically we concentrate on awareness and information supply. To serve the patient in the best way, we also have to concentrate on the health professional.
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ICMCC Event 2008 Program

The preliminary program of the ICMCC event 2008 has been announced.

Immunizations: The First Step in a Personal Health Record to Empower Patients

Abstract:
Despite the promise of better health care through information-centric patient empowerment, little progress has been made. The issue is not that the data do not exist in a useable form, nor that technologies are lacking that would enable access to this information. There are two primary challenges standing in the way of patient empowerment: (1) in the private sector there is no proven revenue model for providing this access and (2) in the public sector the standard argument is confidentiality of information. The lack of a priority by either private or public health providers to empower individuals will lead to these initiatives being consumer driven. Access to immunization records through health informatics and supporting compunetics presents an easy-win opportunity to significantly empower individuals with their own health information.
Scientific Technologies Corporation (STC) has been implementing and supporting immunization registries in North America for over fifteen years. As the leading expert in this area, STC has developed a process for achieving successful large-scale access to personal immunization records with minimal investment. As a first step to empower individuals with on-line access to their immunization records, the STC approach leverages the technical frameworks established for health insurance and 3rd party payer environments linking to statewide immunization information systems. The individual is provided access to their records through their insurer’s health portal. This is populated through electronic exports of member immunization records as retrieved from state or provincial registries that contain provider-supplied patient records, allowing individuals to utilize these hosted services or download their provider administered records into their personal health record.
Individuals have the ability to review their immunization and their family immunization histories. They have the ability to know when an immunization is due, where vaccines are available, and which vaccines minimize risks to disease. For the emerging industry of on-line personal health records, a patient’s immunization record will be the single most important factor to demonstrate success for patient empowerment. It will create a roadmap to support the inclusion of other medical information.

Michael L. POPOVICH^a, Jeffery J. ARAMINI^b, Michael GARCIA^a
a Scientific Technologies Corporation, Tucson, USA
^b Scientific Technologies Corporation, Ontario, USA

To be published in “Medical and Care Compunetics 5″, IOSPress, 2008.
To be presented at the ICMCC Event 2008.

The Safe Implementation of Research into Healthcare Practice

Abstract:
Miscommunication, misunderstanding and outright error have all played significance roles in triggering Adverse Events across the spectrum of health care delivery. As a means of countering these effects this paper outlines a twin track approach. This firstly focuses on developing a care pathway modelling approach both as the basis for better understanding of interdisciplinary process interaction, and also as a means of rapid access to relevant clinical knowledge. This is then set in the context of the human behavioural issues that can all too easily prejudice patient safety. It also explores the potential to apply the large body of knowledge and experience in risk management techniques applied to life critical decision taking under high stress conditions.

Bryan MANNING and Stephen BENTON^b
University of Westminster, School of Informatics and Centre for Business Information, Organisation, and Process Management, Westminster Business School
^b Business Psychology Centre, University of Westminster, Department of Psychology

To be published in “Medical and Care Compunetics 5″, IOSPress, 2008.
To be presented at the ICMCC Event 2008.

Sessions Overview (ICMCC Event 2008)

Papers are published in the proceedings in the Medical and Care Compunetics 5, Studies in Health Technology and Informatics by IOSPress

National and Regional Projects
Aspects of Electronic Health Records
European Projects
Knowledge Management
Platforms
Behavioral Compunetics
Empowerment
Personal Health Paradigm Challenging Citizens and Patients
Empowering Disabled People with ICT Tools

National and Regional Projects

• Jagjit Singh Bhatia, Sagri Sharma
  Telemedicine Endurance - Empowering Care Recipients in Asian Telemedicine Setup
  Presentation
• Wouter Meijer
  The Patient’s Perspective in the Dutch National Technical Agreement on Telemedicine
  Presentation
• Roxana Antohi, Cristina Ogescu, Daniel Bistriceanu, Livia Stefan, Silviu Dumitru
  Electronic Health Records (EHR) in PROMED platform in accordance with the Romanian legislative framework
  Presentation
• Ola Göransson, Krister Pettersson, Pär A Larsson, Bo Lennernäs
  Personals Attitudes towards Robot Assisted Health Care – a pilot study in 111 respondents
  Presentation
• Jeffery J. Aramini, Xiaohui Zhang, Michael L. Popovich
  Colorectal Cancer Screening – Using Informatics and Compunetics to Empower the At -risk Individual

Aspects of Electronic Health Records

• VA Currall, TJ Chesser
  Computer Generated Operation Notes
  Presentation
• Dr. Brian Fisher
  Patients using record access – sharing control
  Presentation
• Catherine Quantin, Maniane Fassa, Gouenou Coatrieux, Vincent Breton, Jean Yves Boire, François André Allaert
  Giving patients secure « google-like » access to their medical record
  Presentation
• Luis Kun, Gouenou Coatrieux, Catherine Quantin, Regis Beuscart, with consultations, and contributions from Robert Mathews
  Improving outcomes with interoperable EHRs and secure global health information infrastructure
  Presentation

European Projects

• Bárbara Vallespín, David Fonollosa, Albert Alonso, Josep Roca
  The deployment of integrated care services for chronic patients (NEXES)
  Presentation
• Christos Malliopoulos, Alexis Milsis, Theodoros Vavouras, Rita Paradiso, Albert Alonso, Domenico Cianflone
  Continuous Mobile Services for Healthcare: the Healthwear project
  Presentation
• Thomas Pliakas, Serafeim Dermeitzoglou, Christos Papachristos, Artur Krukowski
  A Tele-Medicine Service over Satellite Network (HOST)
  Presentation
• Andy Marsh, Christos Biniaris, Dimitrios Vergados, Arnold Eppler, Christoforos Kavvadias, Olaf Bigalke, Eric Robert, Boro Jerabek, Alevizos Alevizos, Michael Caragiozidis
  An Assisted-Living Home Architecture with Integrated Healthcare Services for Elderly People (INHOME)
  Presentation
• HEARTFAID
  Presentation

Knowledge Management

• Fabiola Fernández, Laura M. Roa, Manuel Prado
  Functional and Technological Description of a Real-Time Data Management System for Telehealthcare
  Presentation
• Doug Orendorff, Alex Ramirez and Elayne Coakes
  Validating A Knowledge Transfer Framework in Health Services
  Presentation
• Lilia Edith Aparicio Pico, Orlando Rodriguez Cuenca, Daniel José Salas Alvarez Piere, Augusto Peña Salgado
  Knowledge Management Model for Teleconsulting in Telemedicine
  Presentation
• Juerg P. Bleuer, Kurt Bösch, Christan A. Ludwig
  InWiM: Knowledge Management for Insurance Medicine
  Presentation
• Nilmini Wickramasinghe, Rajeev K Bali, M Chris Gibbons, Jonathan Schaffer
  Realising the Knowledge Spiral in Healthcare: the role of Data Mining and Knowledge Management
  Presentation

Platforms

• Cristina Ogescu, Claudiu Plaisanu, Florian Udrescu, Silviu Dumitru
  Improving Healthcare Services using Web Based Platform for Management of Medical Case Studies
  Presentation
• H.R. Singh and Manju Singh
  Design and Development of a Knowledge driven Web based ECG Data monitoring and Diagnostic Tool in Lab-view
  Presentation
• Isabel Román, Jorge Calvillo, Laura M. Roa and Germán Madinabeitia
  Improving Healthcare Middleware Standards with Semantic methods and technologies
  Presentation
• Claudiu Plaisanu, Daniel Niculae, Cristina Ogescu, Cristina Stefan
  Intelligent information system for treatment response monitoring and prognosis establishment on genital neoplasia patients
  Presentation

Summary by session chair M. Popovich.

Behavioural Compunetics

• B.Manning and S. Benton
  The Safe Implementation of Research into Healthcare Practice
  Presentation
• H.G. van der Roest, F.J.M. Meiland, T. Haaker, E. Reitsma, H. Wils, C. Jonker, R.M. Dröes
  Finding the service you need: Human centered design of a Digital Interactive Social Chart in DEMentia care (DEM-DISC)
  Presentation
• Heather Taylor and Stephen Benton
  The Doctor-Manager Relationship: A Behavioural barrier to Effective Health Care?
  Presentation
• Ruth Gardiner
  The Transition from ‘Informed Patient’ Care to ‘Patient Informed’ Care
  Presentation
• B.R.M. Manning, J. McCann, S. Benton, J. Bougourd
  Active Ageing: Independence through Technology Assisted Health Optimisation
  Presentation

Empowerment

• M Chris Gibbons
  Populomics
  Presentation
• Debora Martinez, Pedro Ferriol, Xisco Tous, Miguel Cabrer and Mercedes Prats
  Virtual Health Platform for Medical Tourism Purposes
  Presentation
• Filipa Falcão-Reis, Altamiro Costa-Pereira, Manuel E. Correia
  Access and Privacy Rights Using Web Security Standards to Increase Patient Empowerment
  Presentation
• Michael L. Popovich, Jeffery J. Aramini, Michael Garcia
  Immunizations: The First Step in a Personal Health Record to Empower Patients
  Presentation

Personal Health Paradigm Challenging Citizens and Patients

organised by Prof. Bernd Blobel
Special Session organised by the European Federation for Medical Informatics, Working Groups “Electronic Health Records” and “Security, Safety and Ethics”

• Bernd Blobel, PhD, Associate Professor, eHealth Competence Center, University of Regensburg Medical Center, Regensburg, Germany
  Architectural approaches to health information systems for empowering the subject of care
  Presentation
• Heather Grain, Llewelyn Grain Informatics and China Health Program, La Trobe University, Australia
  Changes in doctor-patient relationships for realizing the personal health paradigm
  Presentation
• Pirkko Nykänen, PhD, Associate Professor, Tampere University of Technology, Tampere, Finland
  Requirements for user-friendly personal health information systems
  Presentation
• Pekka Ruotsalainen, PhD, Research Professor, STAKES, Helsinki, Finland
  Finland’s strategy and implementation of citizens’ access to health information
  Presentation
• Colin Nolder, presented by Fleur Fisher
  Security and privacy challenges for personalised care – the NHS-approach
  Presentation
• Jane Grimson, PhD, Professor, Trinity College, Dublin, Ireland
  PHR solutions – an Irish perspective
  Presentation
• Peter Pharow, Senior Scientist, eHealth Competence Center, University of Regensburg Medical Center, Regensburg, Germany
  How can the German Electronic Health Card support patient’s role in care management
  Presentation

Empowering Disabled People with ICT Tools

organised by Prof. Giuseppe Tritto, President of the WABT (World Academy of Biomedical Technologies)

• Giuseppe Tritto, President WABT (ICET/UNESCO), World Academy of BioMedical Sciences and Technologies, Paris, France
  Disability definitions and trends for e-Health policies and services
• Malcolm Clarke, Senior Lecturer in Data Communication Systems and Telemedicine, Department of Information Systems and Computing, Brunel University, UK
  Empowering Mr Green with ICT tools
• Marco Rogante, Dipartimento Tecnologie e Salute (Technology and Health Dept.), Istituto Superiore di Sanità (Italian National Institute of Health), Rome, Italy
  ICT for home-based service to maintain the upper limb function: a telerehabilitation experience
• Giuseppina Anna Di Lauro, CEO DEDALO SOLUTIONS, President Club of Spin-off Companies, Scuola Superiore Sant’Anna, Pisa, Italy
  A New Generation of Assistive Technologies: the robot appliance for eating

Call for Papers ICMCC 2008

The call for papers is closed.

For its fifth annual event, ICMCC will focus on the power of information. Information is both the result of data put to use and, once combined with experience, the basis of knowledge. If used properly it can empower patients, both actively and passively.
Information is one of the primordial aspects of medical and care compunetics, the field of social, societal and ethical aspects of computing and networking.
Therefore information related aspects will be at the core of the 2008 event program and this call for papers.

The main themes of the conference are:

• Electronic Health Record (EHR) Approaches
• Patient Record Access
• Compunetics (Social, societal and ethical issues of ICT)
• Data- , Information-, Knowledge Management

Authors are encouraged to focus their contributions from a patient’s perspective.

Accepted papers will be published in “Medical and Care Compunetics 5″ (IOS Press - “Studies in Health Technology and Informatics”) available at the conference.

Click here for author guidelines.

Papers can be sent as mail attachments to 2008 [at] icmcc [dot] org mentioning “Event paper” in the subject line before February 18, 2008.

The following is a non-restrictive list:

Electronic Health Record (EHR) Approaches

• EHR solutions and their comparison
• National and regional EHR strategies
• EHR data quality criteria, quality evaluation schemes and consequences of an insufficient data (and information) quality management
• Personalization of EHR
• EHR vs. PHR - should there be a split up?
• Urban and rural aspects of EHR and access to such EHR
• Security, safety and privacy aspects for access control systems (authentication, authorisation, authenticity, integrity, confidentiality, accountability)
• Record summaries (subset, extract) vs. comprehensive record structures
• Linking to additional (health-related) information (lifestyle, wellness; linkage tokens and mechanisms
• Storage and storage system access (central, de-central, local, distributed, private)
• Long-term archives and self-management of stored information including data management
• Existing and emerging standards for EHR architectures
• Aspects of ownership of EHRs and EHR systems
• Empowerment of health professionals towards extended ICT use

Patient Record Access

• Active patients accessing generic record structures
• Access rights handling (read, write, create, update, lock, delete; clinicians, nurses, patients)
• Access systems (kiosks, internet, cards, sticks, devices)
• Benefits of permanent record access (for patients and clinicians, economic aspects, cost-benefit-relationship, impact on health, impact on treatment, impact on recovery, health outcome)
• Legal and ethical aspects of accessing records (e.g. 3rd party information, parental access)
• Social aspects of accessing records (especially access by (mentally-)incapacitated and (physically-)disabled persons and 3rd party access)
• Training / further education and eLearning aspects for useful and usable record access (health professionals, patients, relatives)
• Relevant standards inside and outside the healthcare and welfare domain
• Record Access policy and use (national, EU, USA, WHO)
• Critical issues and issue resolution
  • Errors (e.g. patient and clinician agree the data is wrong)
  • Conflicts (one of the patient or clinician feel the data is wrong)
  • Disclosure (The patient and clinician disagrees with the level of disclosure or sharing)

Compunetics

• Role of compunetics in treatment and after-care
• Role of compunetics in information gathering and dissemination
• Role of compunetics in quality management
• Community and individual engagement through health IT
• Use of ICT to make protocols more adaptable, more patient-specific and more safe
• Modeling concepts
• Patient behavioral aspects

Data- , Information-, Knowledge Management

• The links and dependencies between data, information, knowledgement
• Use of secondary data for different purposes (incl. scientific studies)
• Orphan diseases
• Disease surveillance and surveillance systems
• Management of (anonymous) EHR data to provide information to the patient
• Anonymization and pseudonymization as challenge to information systems
• Storage of Patient data:
  • where
  • How long
  • Costs
  • Use and sharing policies and who maintains those

ICMCC Blog

ICMCC’s president Lodewijk Bos starts today a regular blog on the ICMCC website.

In his first entry he expresses his wishes for the New Year:

• We would like to invite you, wherever you are in the world, to send us links to interesting articles (news as well as scientific) concerning medical and care ICT in your region or country or in your professional area.
• Much research is done all around the world especially by university institutions and their students. However, outside their own faculty community, hardly anybody knows what they are doing. This is one of the main causes of the reinvention of the wheel as far as research is concerned. ICMCC would like to offer its website as a presentation platform for these university schools to tell us about their past, present (and maybe future) work.
• Create “knowledge centres” like the one on Record Access, on the use of compunetics in other medical and care areas.

New Year’s wishes

My New Year’s wishes

This is my first blog entry on the ICMCC website.

And I would like to start by expressing my joy about the large number of visitors to our site during the last couple of months (see here).

As I have expressed at various occasions during the last years, I would like to see the ICMCC site as a repository of information on medical and care ICT, with a strong emphasis on patient related aspects (compunetics).
The ICMCC Portal on Record Access is an important example of a small knowledge centre, where an overview is given of the various aspects of (patient) record access.
The ICMCC news page, which gives an up-to-date overview of news and science articles as well as reports related to medical and care ICT has become an important source of information. It is used as the main news supplier of the HoIP page. It is painstakingly updated on a daily basis. However, we realise that much information is missing, especially at national and local levels. This is partly due to language, but also because it is very difficult to keep an even larger overview than we already have.

Here are my New year’s wishes:

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Medical and Care Compunetics: The Future of Patient-Related ICT

“This article deals with the role of compunetics in the future of patient related ICT (information and communication technology). The role of information, the development of knowledge centres, the collection and utilisation of data and the development of patient networks and e-learning are discussed.”
Abstract
Lodewijk Bos, JITH, 1 October 2007

Health Inequalities and Emerging Themes in Compunetics

M. Chris Gibbons, MD, MPH
Johns Hopkins Urban Health Institute, Johns Hopkins Medical Institutions, USA

Abstract

Inequalities in health have been documented for hundreds of years. The causes of these inequalities are complex and related to social, medical, environmental, class, healthcare system and behavioral determinants. Currently governments and healthcare systems are struggling to effectively reduce these differences. In addition, the number of individuals with chronic diseases is rapidly growing, particularly in developed nations. Most of the care needed for effective management of these chronic diseases is performed outside of the hospital setting by non-physicians. However the world’s healthcare systems are primarily oriented toward acute, hospital based emergency care and therefore currently largely unable to effectively and consistently provide high quality care to every person.

Recent developments in the computer industry have led to major advances in scientific research capabilities and in like manner will, in the future, likely enable significant advances in the field of compunetics. By enabling the instantaneous capture and utilization of large amounts of diverse data, IT will facilitate a population level orientation in compunetics in addition to the current focus on individual patient applications. Similarly the development of behavioral compunetics or a focus innovative uses of technology to influence health behaviors of patients and physicians are on the verge of occurring. In so doing, these and other advances in compunetincs may significantly increase our ability to provide high quality community oriented care, improve the health of individuals and populations and thereby help reduce health inequalities.

Patient Centered (Health) Care Solutions

Workhop Organizers:
Dr Andy Marsh, VMW Solutions, UK
Denis Carroll, Westminster University, UK

Description

Maturing telemedicine technologies, struggling mobile networking revenues and increased personal healthcare awareness have provided the foundations for a new market niche that of “Healthcare Compunetics”. During the last 5 years, telemedicine (based on internet and web technologies) is becoming a reality both in terms of developing technologies and supportive legislation. Within Europe, wireless infrastructures have received a huge investment and although not well defined in how it will be achieved healthcare has been identified as a major stream of revenue with personal healthcare (e.g. EHCR on the handset) being a key issue especially for the handset manufactures.

Patients in the 21st Century are expecting a patient-centred service, safe, high quality treatment, comfortable accommodation services, fast access and an integrated joined-up system. The uptake of integrated Information and Communication technologies (ICT) will be crucial. Healthcare compunetics, the combination of computing and networking customized for healthcare, will provide the common policy and framework for combined multidisciplinary research, development and implementation.

Accepted papers

• Safety Aspects of (Not) Using ICT in Health Care
  A.C.M. Dumay, G. Freriks, TNO, The Netherlands
  Presentation (1,6 Mb)
• Emotional Prosody Measurement (EPM): A Voice-based Evaluation Method for Psychological Therapy Effectiveness
  E. van den Broek, University of Nijmegen, The Netherlands
  Presentation
• MET System: a New Approach to M-health in Emergency Triage
  W. Michalowski, University of Ottawa, Canada
  R. Slowinski, S. Wilk, Poznan Technical University, Poland
  Presentation
• The Changes Caused by Modification of Biomechanical Properties of a Bone
  M. Binkowski, Z. Wróbel, A. Dyszkiewicz, Silesian University, Poland
• Web-based Asthma Collaboration Management and Public Awareness
  M. Glykas, P. Chytas, University of Aegean, Greece
• Extended Possibilities of Pharmaceuticals Delivery to Patients Using Dematerialized Prescriptions
  A.P. Urbansky, Technical University Poznan, Poland
• Vibroacoustic Sound Therapy:
  Case Studies with Children with Profound and Multiple Learning Difficulties and the Elderly in Long-Term Residential Care
  P. Ellis, University of Sunderland, UK
• An Electronic Patient Record Implementation Using Clinical Document Architecture
  M. Poulymenopoulou, G. Vassilacopoulos, University of Piraeus, Greece
• Mobile Guidelines for Pharmacologic Treatment of Hypertension
  P. Eklund, Annica Näslund, Umeå University, Sweden
• Artificial Neural Networks as an Engine of Internet Based Hypertension Prediction Tool
  S. Polak, A. Mendyk, Jagiellonian University, Poland
• Development of a Clinical Pathways Analysis System with Adaptive Bayesian Nets and Data Mining Techniques
  D. Kopec, Brooklyn College, USA
  G. Shagas, Brooklyn College, USA
  D. Reinharth, Albert Einstein School of Medicine, USA
  S. Tamang, Brooklyn College, USA
• Development of an Expert System for Differentiating Tension Type Headaches from Migraines
  D. Kopec, Brooklyn College, USA
  G. Shagas, Brooklyn College, USA
  J. Selman, Albert Einstein School of Medicine, USA
  D. Reinharth, Albert Einstein School of Medicine, USA
  S. Tamang, Brooklyn College, USA
• Power to the Patient, Using DI@L-log
  L. Black, M. McTear, N.D. Black, University of Ulster, Northern Ireland
• Robotic Technology Applied to Meet the Requirements of Tools to Support Microsurgery and Cellular Surgery
  P. Brett, Xianghong Ma, University of Aston, Birmingham, UK
  G. Tritto, Hopital Saint Louis, Paris, France
• Errors in Medical Practice: Identification, Classification and Steps Towards Reduction
  D. Kopec, Brooklyn College, USA
  G. Shagas, Brooklyn College, USA
  M. Kabir, McGill University, Montreal, Canada
  D. Reinharth, Brooklyn College, USA
  J. Castiglione, Albert Einstein School of Medicine, USA
  S. Tamang, Brooklyn College, USA
• Interactive Telemedicine as a Tool to Avoid a Digital Divide in the World
  G. Graschew, T.A. Roelofs, S. Rakowsky, P.M. Schlag, Max-Delbrueck-Center for Molecular Medicine and Robert-Roessle-Klinik, Charité - University Medicine Berlin, Germany

Papers only published in Proceedings:

• An Implementation of the Trigram Phrase Matching Method for Text Similarity Problems
  Adalberto O. Tardelli, Centro Latino-Americano e do Caribe de Informação em Ciências da Saúde, Brasil
  M.S. Anção, Universidade Federal de São Paulo, Brasil
  A.L. Packer, Centro Latino-Americano e do Caribe de Informação em Ciências da Saúde, Brasil
  D. Sigulem, Universidade Federal de São Paulo, Brasil
• Using the Sense of Smell in Telemedical Environments
  B.S. Spencer, Nova Southeastern University, Fort Lauderdale, USA