A Pilot Project to Improve Access to Telepsychotherapy at Rural Clinics

A Pilot Project to Improve Access to Telepsychotherapy at Rural Clinics
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  Meeting the Continuing Education Needs of Rural Mental Health Providers Geri Adler, PhD, Lonique R. Pritchett, PhD, LCSW,and Michael R. Kauth, PhD Veterans Affairs South Central Mental Illness Research,Education, and Clinical Center, Houston VA Health Services Research & Development Center of Excellence, Houston, Texas; Baylor College of Medicine, Houston, Texas. The views expressed are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs,the U.S. government, or Baylor College of Medicine.  Abstract Background:   Historically, mental health clinicians at Department of  Veterans Affairs (VA) community-based outpatient clinics (CBOCs)have not had the same access to continuing education (CE) as providersat VA medical centers. Mental health clinicians at CBOCs desire anopportunity for VA-sponsored CE, especially on topics and issues pertinent to rural mental healthcare.  Materials and Methods:   Since  November 2011, VA CBOC mental health providers in 11 states have been offered a monthly live Web conferencing CE program. This article describes the program’s development, implementation, and evaluation. Results:   Eleven CE programs have been offered to 397 unique partic-ipants. Participants have provided positive feedback about the topicsand their impact on job performance. Most negative feedback has beenrelated to technical and logistical problems with the Web conferencing platform. Although providers asked for reportable CE units for licen-sure, many did not complete the post-test, which is required to receive credit for completing the course.  Conclusions:   The Web conferencing format has been well received by participants. Despite technical issues,results show that the participants were satisfied with the content of the trainings and could apply the materials to their job. Although CE unitswere available, not all participants applied for credit. Efforts to improve technical support and the rate of post-test completion are discussed.Rural mental health providers often have limited access to trainingopportunities. The VA CBOC Mental Health Rounds, using an inter-active Web conferencing platform, has been a successful modality for delivering CE to rural clinicians in the United States. Key words:  Web conferencing, rural, Veteran, continuing education Introduction M ental health clinicians in rural settings often lack theeducational support and professional developmentopportunities available to their urban counterparts. 1,2 To provide evidence-based practice to patients in ruralsettings, mental health clinicians need specialized training in areassuch as dual relationships, overlapping and conflicting roles, andchallenges in preserving patient confidentiality that are unique tothat environment. 1–3 These issues can be addressed in training of-fered to providers. Not only are their training needs varied and dif-ferent from those of urban practitioners, but limited access tocontinuing education (CE) opportunities contributes to delays inincorporatingthelatesttreatments,techniques,andresearchfindingsinto clinical practice. Consequently, CE targeting rural providers canaddress their unique training needs, foster clinical competence, im-prove patient outcomes, and lead to greater job satisfaction. 4,5 The Veterans Health Administration provides a broad range of medical benefits to Veterans at Department of Veterans Affairs (VA)medical centers (VAMCs) and community-based outpatient clinics(CBOCs) throughout the United States and its territories. CBOCs wereestablished to provide care nearer to a Veteran’s home than a tertiary  VAMC. 6,7 Today there are over 800 CBOCs, many in rural areas,operating in conjunction with 157 VAMCs. 8  All CBOCs offer primary care, and many offer mental health services as well. 6,7 CBOCs have aprimary care physician, and most CBOCs have at least one mentalhealth provider, often a psychologist, social worker, or nurse. 9  An estimated 1.3 million rural Veterans in the United States suffer fromamentalhealthdisorder. 10 Mentalillnesscanbeoneofthemostdebilitating of diseases. 11 Rural Veterans experience greater severity of mental health symptoms, 12 have higher rates of suicide, 13 and areless likely to receive psychotherapy than urban Veterans. 10,14 Giventhe magnitude of the problem, addressing the training needs of ruralmental health providers warrants attention. Veterans Integrated Service Network (VISN) 16 is located in one of the most rural areas in the United States, including all or parts of eight southeastern and south-central states. It has over 50 CBOCsassociated with 10 VAMCs. 15  VISN 16 serves 445,000 Veterans, over 80,000 with mental health problems, and more than half residing inrural settings. 8,15 The South Central Mental Illness Research, Edu-cation and Clinical Center (SC MIRECC), a virtual center within VISN16, is dedicated to improving the provision of healthcare services to Veterans living with mental illness. 8 Its mission is ‘‘ . to promoteequity in engagement, access, and quality of mental healthcare for  Veterans facing barriers to care, especially rural Veterans.’’This article describes the development, implementation andevaluation of a monthly Web conference training program for VA CBOC mental health providers. Materials and Methods  With the support of VISN 16 leadership, the SC MIRECC developedand sponsored a distance-learning educational program known as 852 TELEMEDICINE and e-HEALTH  NOVEMBER 2013 DOI: 10.1089/tmj.2013.0010  the CBOC Mental Health Rounds. Justification for the project wasbased on the SC MIRECC’s work with individual CBOCs and the re-sultsof the annualVISN-wide clinical education needs assessment of CBOC mental health providers, a short survey asking clinicians torank their top training priorities. A strong value of the VA healthcaresystem is that clinical providers receive CE in new research findingsandproven clinicalpractices.CBOCproviders reported limitedaccessto VAMC-based CE opportunities, primarily because of the signifi-cant time required for traveling to their parent facility for off-sitetraining. In particular, providers desired educational activities thatcould help to fulfill their professional license requirements. Face-to-face training was considered optimal, conducive to the learningprocess and creating opportunities for networking. However, con-sidering the distance to most education programs offered at their parent VAMC, the difficulties canceling clinics or arranging cover-age to attend an off-site meeting, and tuition cost for a non– VA-sponsored educational event, clinicians were amenable todistance-learning formats that would allow them to remain in their work setting and have access to free CE opportunities. Also, givenCBOC providers’ busy schedules, 1-h trainings were preferred.Finally, providers were interested in and enthusiastic about topicspertinent to rural mental health.To address the lack of CE activities available to rural providers, theCBOC Mental Health Rounds were developed. Using a live Webconferencing platform, the inaugural training was launched in No- vember 2011. This system concurrently uses two separate technol-ogies: (1) the VA National Teleconferencing System to carry theaudio and (2) Microsoft  (Redmond, WA) Live Meeting (a sub-application of Outlook) to carry the visual (PowerPoint slides). Par-ticipants are able to ask questions and discuss the topic with thepresenter, using the audio line. They are able to interact as well viatheir computer to answer polling questions, use the chat feature, andgive feedback about the pace of the session. By agreement of clinicalleaders, the VISN 16 clinicians were given release time for partici-pationintherounds.InJuly2012,theserieswasexpandedtoVISN6,the Mid-Atlantic Healthcare Network. VISN 6 has a strong interest inrural mental health and an established process for communicatingwith its CBOC clinicians. It serves over 320,000 Veterans at its eightmedical centers and 27 CBOCs in North Carolina, Virginia, and West Virginia. 16 To ensure that the CBOC Mental Health Rounds address the uniquetrainingneedsandinterestsofruralproviders,aneducationplanningcommitteewasformed. Thecommittee meetsmonthly andcomprisesCBOC providers from a variety of disciplines and VA EmployeeEducation System (EES) staff. CBOC members oversee the planningprocess. They identify content, select topics, recommend speakers,establish objectives, ensure sessions adhere to licensure board cri-teria, review evaluations, and suggest areas for improvement. EES isthe administrative body in the VA that supports employee training.EES provides guidance on execution of the project’s activities, in-cluding registration, accreditation, marketing, preparing faculty for using the Live Meeting space, and troubleshooting technical issues.Collectively, members ensure that the sessions are high quality, meetstandards for accreditation, and address topics salient to a broadrange of rural mental health providers.Despitethechallenges ofdesigningacurriculum tofittheneedsof a diverse group of mental health professionals with varied expertiseand work demands, the training series has entered its second year.The program is offered the first Wednesday of every month. Twoweeks prior to each month’s session an announcement is sent tomental health providers, medical center directors, and other VA employees via e-mail. The message includes a description of thatmonth’s educational session, a registration link, and dates and topicsof upcoming trainings. This same information is also posted on aSharepoint site within the VA system and the SC MIRECC Internet Web site. Ongoing reminders are sent during the 2 weeks leading upto the session. The presentations are 1h in length, including time for questions and discussion.CE units (CEUs) areavailable fornurses, physicians, psychologists,social workers, and other healthcare professionals. To receive CEUs,participants are required to pass an online post-test with a minimumscore of 80% correct. The post-test comprises 10 multiple-choice andtrue/false questions, based on that month’s topic. In addition, par-ticipants are invited to complete an online post-training evaluation.The 26-item questionnaire concentrates on participant satisfactionwith the trainings’ content, objectives, job impact, and learning en- vironment. Most questions are on a 5-point ordinal scale, rangingfrom strongly disagree (1) to strongly agree (5). Four questions areopen-ended, giving participants an opportunity to give feedback regarding the strengths and weaknesses of the session itself and thetechnology. Results During its first year of implementation, 11 CBOC Mental HealthRounds were offered to 397 unique participants. The sessions wereattended by VA employees from various disciplines. Social workersrepresented the predominant discipline in attendance ( Fig. 1 ).Overall,89–98%ofparticipantsagreedthatthepresentationswerea satisfying learning activity that they would recommend to others( Table 1 ) Most found the content of the trainings appropriate, noting Fig. 1.  Community-based outpatient clinic Mental Health Roundsparticipants, by discipline. WEB CONFERENCING CE FOR RURAL PROVIDERS ª  MARY ANN LIEBERT, INC.    VOL. 19 NO. 11    NOVEMBER 2013  TELEMEDICINE and e-HEALTH 853  that topics such as ethics met specific CEU needs for licensure re-newal.The learning environment was evaluated primarily throughquestionsabouttheWebconferencingtechnology.Morethan87%of participants reported overall satisfaction with the technology, and86%founditeasytouse.Beingabletoaccesstheprogramsfromtheir workstations was considered a plus by many participants. Despitebeing generally satisfied, participants often reported that improve-ments needed to be made in ease of use of the technology. Technicalproblems included delays dialing into the teleconferencing system,background noise from participants who did not mute their phoneduring the presentation, and becoming unexpectedly disconnectedduring a training session. These participants suggested more tech-nical support be made available during the meetings to addresssystem problems ( Table 1 ).Thetrainingshadapositiveimpactonparticipants’jobs.Over91%reported that they are/will be able to apply the knowledge and skillslearned in the sessions to their current position. Additionally, over 81% of participants reported that the learning activity will improvetheir job performance. Up-to-date information on evidence-basedtherapies, clarification of VA policies and procedures, and researchtrends were considered useful by many participants. Table 1. Mean Program Evaluation Scores and Percentage Agreement, Based on 11 Sessions SESSION a PARTICIPANT SATISFACTIONQUESTIONS A B C D E F G H I J K Overall, I was satisfiedwith this learning activity.4.47 (97%) 4.46 (96%) 4.31 (97%) 4.26 (90%) 4.59 (98%) 4.21 (90%) 4.44 (96%) 4.19 (89%) 4.29 (96%) 4.26 (94%) 4.50 (96%)Would recommend thislearning activity to others4.50 (98%) 4.46 (96%) 4.25 (91%) 4.28 (90%) 4.37 (91%) 4.29 (93%) 4.50 (96%) 4.28 (94%) 4.20 (96%) 4.26 (92%) 4.43 (93%)Scope of material was ap-propriate to needs.4.36 (95%) 4.33 (98%) 4.19 (88%) 4.17 (88%) 4.28 (87%) 4.16 (88%) 4.43 (98%) 4.14 (94%) 4.16 (92%) 4.16 (92%) 4.37 (91%)Content relevant to job-related needs4.47 (95%) 4.35 (98%) 4.25 (91%) 4.25 (90%) 4.38 (92%) 4.34 (97%) 4.43 (96%) 4.11 (89%) 4.20 (96%) 4.22 (92%) 4.48 (96%)Able to apply knowledgeand skills learned to job4.56 (96%) 4.35 (96%) 4.13 (88%) 4.14 (88%) 4.28 (89%) 4.21 (95%) 4.33 (94%) 4.14 (89%) 4.14 (90%) 4.12 (88%) 4.28 (91%)Learning activity will helpimprove job performance.4.17 (88%) 4.07 (87%) 3.84 (78%) 3.96 (74%) 4.04 (83%) 3.77 (68%) 4.13 (87%) 3.94 (81%) 3.98 (82%) 3.96 (78%) 4.20 (89%)Appropriate technologyutilized to facilitatelearning4.04 (88%) 4.31 (98%) 4.29 (97%) 4.26 (95%) 4.24 (90%) 4.10 (93%) 4.25 (94%) 4.17 (97%) 4.21 (96%) 4.32 (96%) 4.16 (88%)Training environment wasconducive to learning.4.22 (98%) 4.29 (93%) 4.26 (94%) 4.14 (89%) 4.24 (90%) 3.97 (81%) 4.19 (94%) 4.17 (97%) 4.21 (96%) 4.24 (92%) 4.25 (89%)Technology was easy touse.3.89 (82%) 3.98 (82%) 3.97 (84%) 4.07 (86%) 4.16 (88%) 3.74 (79%) 4.13 (85%) 4.00 (92%) 4.17 (96%) 4.20 (88%) 4.09 (86%)Overall, satisfied with useof technology4.03 (90%) 4.20 (91%) 4.06 (88%) 4.09 (88%) 4.14 (86%) 3.60 (71%) 4.15 (85%) 4.03 (92%) 4.13 (94%) 4.26 (92%) 4.12 (86%)Technology was responsiveand provided access tofurther support.4.00 (86%) 4.05 (86%) 3.87 (84%) 3.98 (79%) 4.14 (88%) 3.74 (76%) 4.22 (91%) 4.08 (92%) 4.16 (91%) 4.12 (88%) 4.05 (81%)Overall average % of thosewho agree90% 91% 87% 85% 87% 85% 91% 89% 90% 88% 89%The rating scale ranged from 1 (strongly disagree) to 5 (strongly agree). The percentages represent the percentages of participants who agree or strongly agree with eachof the statements. a Session titles were as follows: A, Suicide Prevention in Rural Settings; B, Ethics for Rural Providers; C, Tips for Recovery in Rural Settings; D, Providing Recovery OrientedCare in Rural Settings; E, Stress Management for Rural Providers; F, Ethics, Social Media and Rural Practice; G, Managing TBI [Traumatic Brain Injury] Among Veterans inRural Settings; H, Spirituality and Mental Health in Rural Settings; I, Couples Therapy in Rural Practices; J, Treating Rural Veterans with TBI and PTSD [PosttraumaticStress Disorder]; and K, Engaging Families in Recovery.  ADLER ET AL. 854 TELEMEDICINE and e-HEALTH  NOVEMBER 2013  TheprovisionofCEUswasamajormotivationforthedevelopmentof the program. Across all 11 sessions, an average of 87 participantsregistered for the trainings. It is surprising, however, that only 49participants on average passed the post-test and that even fewer (46participants) completed the post-test evaluation, which is required toobtain CEUs. Discussion The CBOC Mental Health Rounds provide mental health providerswith a live Web conferencing training opportunity. The format en-ables participants to improve their knowledge of evidence-basedpractices and rural mental health issues, strengthen clinical skills,andreceiveaccreditedhoursthatcanbereportedtowardprofessionallicensure. In addition, distance-learning opportunities reduce costin staff travel time and absences associated with distant on-siteprogramming.Participants ranked their overall satisfaction with the trainings inthe 89–97% range for each session. Because of the diversity of thelearners in terms of discipline and geographic location, the sessionshave spanned a variety of rural mental health topics. For example,suicide is a major concern for Veterans in rural areas, where suiciderates and risks exceed those of urban dwellers. 17 The opening pre-sentation, ‘‘Suicide Prevention in Rural Settings,’’ enhanced partici-pants’ skills in developing and implementing a safety plan. A later presentation on spirituality compared and contrasted the roles of CBOC mental health providers and local clergy in providing supportfor Veterans and their families. A range of presenters, includingCBOC practitioners and national leaders, may have also contributedto overall satisfaction.Several studies indicate that rural providers experience difficultiesaccessing CE. 1,4,18  Web conferencing has been shown to be an ef-fective alternative to face-to-face training because of its cost-efficiency and convenience for rural providers, who would otherwiseneed to travel far distances for training. 18,19  Although much dataexist to support the cost efficiency of Web conferencing for tele-health, data on the cost efficiency of Web conferencing for CE arescarce. However, some studies indicate that providing CE via a Webconferencingformatcansavehospitals intravel(forboththespeaker and attendees) and loss of productivity of hospital staff, as well asfacility costs. 2 By participating in the CBOC rounds, clinicians wereable to access CE opportunities at their own sites, eliminating timelost to travel and minimizing disruptions to the care of their patients.Just as in previous studies, we found that rural providers weresatisfiedwiththeWebconferencingformatforCE.Likethoseinother settings that offer Web conferencing, 18 our participants sometimesencountered technical difficulties, including poor audio quality andinterferingbackgroundnoisescausedbyunmutedmicrophonesfromother users. Offering consistent and reliable technical support introubleshooting issues with technology may help to decrease frus-trationand,overtime,improveeaseofuse. 1,18  Wefoundthat,despitethe challenges with technology, participation in trainings remainedconsistent across all sessions offered, indicating that technology wasnot a major barrier.ResultsindicatethatprovidershavefoundtheCBOCMentalHealthRounds valuable to their job performance. Providing relevant anduseful CE opportunities is integral to providing competent and state-of-the-artcare.Identifyingtrainingneedsandselectingcontentwerethe responsibility of the planning committee. Perhaps being clini-cians themselves helped the committee members select topics of  value to their peers.Only participants interested in obtaining CEUs are required tocomplete a post-test. Given the lack of educational opportunitiesfrequently reported by rural providers, the low rate of participantswho applied for credit is surprising. Several barriers may inhibitcompletion. First, completing the post-test requires several steps—participants must exit the Live Meeting, log into the EES Web site,locate the course title, click on a link to the post-test, and completeandsubmitit.ParticipantswouldsometimescontactEESortheseriescoordinator regarding problems with the post-test immediately fol-lowing a Web conference. Some problems encountered when at-tempting to access the post-test immediately following the Webconference included unavailability of the post-test and incompletedisplay of questions. Participants who do not immediately completethe post-test may find it difficult to later fit it into their full clinicalschedules. Although participants can retake the test until a passingscore is attained, waiting several days or even weeks to take the testmay contribute to failing scores. Finally, post-tests are available for completion for only 4 weeks following training. Efforts to increasethe rate of post-test completion are being investigated. Post-traininge-mail messages are now being sent to registrants encouraging themto complete the evaluation and obtain CEUs. In addition, trainingslides are made available for review and download before thetraining, during the training session itself, and post-training. EES isexploring ways to streamline the process. Although this study provides insight into the implementation of and satisfaction with a Web-based CE program, it had several limi-tations.Onelimitationisthatdatawerebasedonlyonresponsesfromparticipants who elected to respond to the survey. Additionally, be-cause participants were evaluated one time post-training, there wereno means of tracking knowledge transfer. Likewise, because of theanonymity of the survey, no information is available as to whocompleted the evaluations, andthere isno information as toprovider overlap. Furthermore, because we lack follow-up data reporting onthe effectiveness of the training, we cannot make judgments as tohow effective the trainings were. Conclusions Evaluations of the CBOC Mental Health Rounds indicate that theprogram has been well received. Using a Web conferencing platform,it has delivered relevant and convenient training to rural mentalhealth providers. However, continued attention must be paid toproviding responsive technical support to users experiencing prob-lems and mechanisms to obtain CEUs.The program’s early success and the needs of its unique audiencehave prompted the VA Office of Mental Health Services to recommendnational expansion. The program has incrementally grown to now WEB CONFERENCING CE FOR RURAL PROVIDERS ª  MARY ANN LIEBERT, INC.    VOL. 19 NO. 11    NOVEMBER 2013  TELEMEDICINE and e-HEALTH 855  include 5 of 21 VISNs and 20 states. As its reach extends to a nationalaudience, the live educational sessions will be offered twice, on twodifferent days of the week and at two different times of day, providingeasieraccesstoproviders.Continuedeffortstoevaluatethemeritsoftheprogram will be made, particularly its impact on patient care.Interest in Web conferencing is expected to continue to grow. Al-though the platform can be cumbersome, it has several advantages,including easy access and an interactive learning environment. Withmany governmental agencies reducing travel budgets for face-to-facemeetings, Web conferencing provides a lower-cost mechanism for ed-ucation and training in large community-based public healthcaresystems.  Acknowledgments This work was partly supported by the Office of Research and De- velopment, Veterans Health Administration, Department of Veterans Affairs,andtheHoustonVAHealthServicesResearchandDevelopmentCenter of Excellence (HFP90-020) and the South Central MIRECC. 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Suicideamong patients in the Veterans Affairs health system: Rural-urbandifferences in rates, risks, and methods.  Am J Public Health  2012; 102(Suppl1):S111–S117.18. Ricci MA, Caputo MP, Callas PW, Gagne M. The use of telemedicine fordelivering continuing medical education in rural communities.  Telemed J E Health  2005; 11:124–129.19. Malay ME, Moore JF. Rural-urban partnering in continuing education.  J ContinEduc Nurs   2002; 33:60–62.  Address correspondence to: Geri Adler, PhDHouston VA Health Services Research &  Development Center of Excellence (MEDVAMC 152)2002 Holcombe Boulevard Houston, TX 77030E-mail:  Received:  January 9, 2013 Revised:  March 6, 2013  Accepted:  March 7, 2013  ADLER ET AL. 856 TELEMEDICINE and e-HEALTH  NOVEMBER 2013
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