The Impact of Telehealthin AlaskaAn 8 Year Retrospective of the AFHCAN Project<br />Stewart Ferguson Ph.D., Director of Te...
2<br />
1,420 miles (2400 km) (N-S)<br />2,400 miles (4000 km) (E-W)<br />ALASKA<br /><ul><li>More shoreline (33,900 miles  or 56,...
75% of Alaskan communities are unconnected by a road to a hospital.
25% Alaskans (46% of Alaskan Natives) live in communities of less than 1000 people.
Population density is 70X smaller than the national average.
49% of all physicians in Alaska are primary care physicians compared to U.S. average of 28%
Alaska is 48th in “doctors to residents” ratio.  65% are located in Anchorage.</li></li></ul><li>
Air travel required:<br />Provider<br />Patient <br />
Case originated…<br />
…Case received.<br />
When Do You Need A Telemedicine Consultation?<br />Uncertain about the diagnosis.<br />Uncertain about the treatment.<br /...
Store & Forward vs Real-Time Telehealth<br />Store & Forward<br />Real-Time (VtC)<br /><ul><li>Asynchronous Interaction
Documents & Images
Electronic Medical Records
Patient Education
Face-to-Face Interaction
Immediate Feedback</li></ul>Remote<br />consultation<br /><ul><li>Radiology
Dermatology
Pathology
Oncology
Ophthalmology
Dental
Cardiology
ENT
GI
Pulmonary
Rheumatology
Psychology/ Psychiatry
Neurology
Speech therapy
Physical therapy</li></ul>Clinical specialties for telemedicine<br />10<br />
Store & Forward Telehealth<br /><ul><li>Asynchronous.
Can create a case “on the run.”
Doctor can respond when available.
Many consults are not critical.
It is needed as a communication tool.
Fits with present model.
Minimal onsite technical support is needed.</li></ul>Low bandwidth requirements<br />Static data – e.g. Vital signs<br />S...
AFHCAN Telehealth<br />9 year Operational History<br />12,000 cases / year<br />Research and Production Telehealth System<...
Alaska: 248 sites, 44 organizations
37 Tribal organizations
US Army sites (6) & US Air Force bases (3)
State of Alaska Public Health Nursing (26)
US Coast Guard clinics (5)
US Coast Guard cutters and ice breakers (6)
Lower 48, Panama, Greenland</li></li></ul><li>13<br />Telehealth Cases Created<br />Patients Involved in AFHCAN Telehealth...
TELEHEALTH<br />Team<br />EXECUTIVE BOARD<br />CEO / Commanders<br />ANMC, VA, USCG, 3MDG, BACH, 354 MDG<br />STEERING BOA...
Ear Disease<br />Audiometer, Tympanometer, Video Otoscope<br />Heart Disease<br />ECG & Vital Signs Monitor<br />Respirato...
A User Interface Designed by Clinicians<br />Simplicity is key for Case Creation.<br />Minimize need for keyboard skills<b...
A User Interface Designed by Clinicians<br />Rich Web Interface for Specialists<br />17<br />
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Impact of Telehealth in Alaska

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Stewart Ferguson PhD
Director of Telehealth
Alaska Native Tribal Health Consortium

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Impact of Telehealth in Alaska

  1. 1. The Impact of Telehealthin AlaskaAn 8 Year Retrospective of the AFHCAN Project<br />Stewart Ferguson Ph.D., Director of Telehealth, ANTHC<br />John Kokesh MD, Chief of Otolaryngology Dept., ANMC<br />Chris Patricoski MD, AFHCAN Clinical Director, ANTHC <br />Phil Hofstetter, Director of Audiology, NSHC<br />Nathan Hogge, AFHCAN Senior Software Architect, ANTHC<br />
  2. 2. 2<br />
  3. 3. 1,420 miles (2400 km) (N-S)<br />2,400 miles (4000 km) (E-W)<br />ALASKA<br /><ul><li>More shoreline (33,900 miles or 56,500 km) than all Lower 48 states combined.
  4. 4. 75% of Alaskan communities are unconnected by a road to a hospital.
  5. 5. 25% Alaskans (46% of Alaskan Natives) live in communities of less than 1000 people.
  6. 6. Population density is 70X smaller than the national average.
  7. 7. 49% of all physicians in Alaska are primary care physicians compared to U.S. average of 28%
  8. 8. Alaska is 48th in “doctors to residents” ratio. 65% are located in Anchorage.</li></li></ul><li>
  9. 9.
  10. 10. Air travel required:<br />Provider<br />Patient <br />
  11. 11. Case originated…<br />
  12. 12. …Case received.<br />
  13. 13. When Do You Need A Telemedicine Consultation?<br />Uncertain about the diagnosis.<br />Uncertain about the treatment.<br />Uncertain about the outcome; complications<br />Specialist participation earlier rather than later<br />“Expert Level Triage”<br />
  14. 14. Store & Forward vs Real-Time Telehealth<br />Store & Forward<br />Real-Time (VtC)<br /><ul><li>Asynchronous Interaction
  15. 15. Documents & Images
  16. 16. Electronic Medical Records
  17. 17. Patient Education
  18. 18. Face-to-Face Interaction
  19. 19. Immediate Feedback</li></ul>Remote<br />consultation<br /><ul><li>Radiology
  20. 20. Dermatology
  21. 21. Pathology
  22. 22. Oncology
  23. 23. Ophthalmology
  24. 24. Dental
  25. 25. Cardiology
  26. 26. ENT
  27. 27. GI
  28. 28. Pulmonary
  29. 29. Rheumatology
  30. 30. Psychology/ Psychiatry
  31. 31. Neurology
  32. 32. Speech therapy
  33. 33. Physical therapy</li></ul>Clinical specialties for telemedicine<br />10<br />
  34. 34. Store & Forward Telehealth<br /><ul><li>Asynchronous.
  35. 35. Can create a case “on the run.”
  36. 36. Doctor can respond when available.
  37. 37. Many consults are not critical.
  38. 38. It is needed as a communication tool.
  39. 39. Fits with present model.
  40. 40. Minimal onsite technical support is needed.</li></ul>Low bandwidth requirements<br />Static data – e.g. Vital signs<br />Static Images<br />Digital camera (megapixel)<br />Scans<br />Captured video images (ENT, Dental, Opthal., Naso.)<br />Video Clips – esp. from video devices<br />Temporal Data: ECG, stethoscope, tympanometer<br />Textual:<br />Health summaries<br />11<br />
  41. 41. AFHCAN Telehealth<br />9 year Operational History<br />12,000 cases / year<br />Research and Production Telehealth System<br />Design  Installation  Training  Support  Marketing<br />12<br /><ul><li>Installed Customer base includes:
  42. 42. Alaska: 248 sites, 44 organizations
  43. 43. 37 Tribal organizations
  44. 44. US Army sites (6) & US Air Force bases (3)
  45. 45. State of Alaska Public Health Nursing (26)
  46. 46. US Coast Guard clinics (5)
  47. 47. US Coast Guard cutters and ice breakers (6)
  48. 48. Lower 48, Panama, Greenland</li></li></ul><li>13<br />Telehealth Cases Created<br />Patients Involved in AFHCAN Telehealth<br />
  49. 49. TELEHEALTH<br />Team<br />EXECUTIVE BOARD<br />CEO / Commanders<br />ANMC, VA, USCG, 3MDG, BACH, 354 MDG<br />STEERING BOARD<br />AFHCP Planning Board Chairman, AFHCP Project Officer, AFHCP Business Office<br />Director, ANMC Data Manager, and Clinical and Tribal Representatives<br />AFHCAN<br />Partners<br />Clinical<br />Training<br />APO<br />Technology<br />Business<br />OrganizationalChart“Communications”<br />Informatics<br />
  50. 50. Ear Disease<br />Audiometer, Tympanometer, Video Otoscope<br />Heart Disease<br />ECG & Vital Signs Monitor<br />Respiratory Illness<br />Spirometer & Vital Signs Monitor<br />Trauma, Skin & Wound<br />Digital Camera<br />Dental Problems<br />Dental Camera<br />General<br />Scanner & Forms<br />Urgent Care / Critical Care<br />Video Camera<br />A Primary Care Tool<br />15<br />
  51. 51. A User Interface Designed by Clinicians<br />Simplicity is key for Case Creation.<br />Minimize need for keyboard skills<br />Touchscreen<br />Color coded<br />16<br />
  52. 52. A User Interface Designed by Clinicians<br />Rich Web Interface for Specialists<br />17<br />
  53. 53. 18<br />
  54. 54. 19<br />
  55. 55. Champions <br />Service<br />Can<br />See potential<br />Create<br />Innovate<br />Nurture<br />Can’t<br />Sustain<br />Grow to large scale<br />Leave something behind<br /><ul><li>Guarantee of performance
  56. 56. Agreed upon expectations
  57. 57. Sustainable and scalable
  58. 58. Accountable
  59. 59. Independent of individuals
  60. 60. Requires support structure </li></li></ul><li>Training Challenges<br />21<br />TRAINING NEW USERS<br />Each year, 35% of the users are using the AFHCAN system for the first time.<br />EMPOWERING EXPERIENCED USERS<br />Each year, 85% of the cases involve only “experienced” AFHCAN users.<br />
  61. 61. Training<br />More than 20 manuals have been developed to augment the training and support provided by our staff.<br />AFHCAN provides training in many different areas such as:<br />Installation and cable management<br />Software administration for IT specialists<br />Clinical use of biomedical equipment<br />Clinical use of telemedicine software<br />Training Offerings:<br />Didactic classes<br />Web based training<br />Manuals<br />Ongoing monthly basis in Anchorage<br />On-site training in the regions<br />CMEs and CEUs available for many classes.<br />Classes include:<br />Desktop User<br />New User Training <br />Training Refresher <br />System Administrator <br />Train-the-Trainer Workshop<br />Non-Clinical Orientation <br />Cart Hardware Upgrade Procedure<br />Orientation to U.S. Telemedicine, for International Doctors<br />
  62. 62. How can Telehealth reduce the cost of health care?<br />Physician’s surveyed at the point of care … on a per-case basis.<br />23<br />
  63. 63. Medicaid StudyDecreased Travel = Cost Savings<br />24<br />Note: For every $1 spent by Medicaid on reimbursement, $7.95 is saved on travel costs.<br />
  64. 64. 25<br />Did viewing this telemedicine case/image affect PATIENT TRAVEL for diagnosis or treatment of this case (compared to a phone consult)?<br /><ul><li> It PREVENTED Patient Travel
  65. 65. It CAUSED Patient Travel
  66. 66. It had NO EFFECT</li></li></ul><li>Impact of Telehealth onPreventing Patient Travel<br />26<br />Patient travel is prevented for almost 80% of all specialty consults.<br />Travel is prevented for about 20% of all primary care cases. <br />Responses were received to the travel question on 13,510 cases<br />
  67. 67. Impact of Preventing Patient Travel<br />27<br />Travel savings generated by the use of AFHCAN telehealth amounts to approximately $14 million for 15,600 patients.<br />Annual travel savings, based on 2007 data, is approximately $3.5 million for 3,800 patients<br />
  68. 68. Impact of Telehealth on Causing Patient Travel<br />28<br />
  69. 69. Providing Care in the Patient’s Community<br />29<br />
  70. 70. Traveling AudiologistTravel Avoidance = Cost Savings<br />
  71. 71. Outcomes<br />About 69% of the patients seen needed something done (meds, surgery, ongoing monitoring) and 27% needed to be screened out.<br />Note: Percentages may not add to 100% due to multiple outcomes per case.<br />
  72. 72. Three remote sites (Jan ‘09)<br />96 Patients imaged<br />66 patients  follow up in 12 mo.<br />30 patients have pathology that require an in-person visit with an ophthalmologist<br />11 with diabetic retinopathy<br />19 with additional pathology: Large optic cups, hard exudates, macular drusen, pseudophakia, ungradeable images with hx <br />IHS/JVN Alaska<br />Diabetic Retinopathy is the leading cause of new blindness among adults<br />Blindness due to diabetes can be eliminated by timely Dx and Tx<br />
  73. 73. Expert Triage Model<br />33<br />80% of all consult prevent patient travel<br />Each year, 1 to 2 cases caused travel <br />
  74. 74.
  75. 75. Average Wait Time<br />35<br />Data courtesy of Phil Hofstetter<br />
  76. 76. Waiting Times&gt; 4 Months<br />36<br />Data courtesy of Phil Hofstetter<br />
  77. 77. Improving Processes<br />37<br />
  78. 78. 38<br />Meeting “Standards of Care”<br />Post-surgical follow-up is difficult for patients from remote settings.<br />Telehealth provides ability to monitor and followup.<br />“Many simple problems, such as tympanostomy tube follow-up can be done with telemedicine without asking the patient to leave their village.“<br />ENT Specialist<br /><ul><li>Validated model
  79. 79. “Reverse Consult” empowers CHA/Ps and midlevels to respond to requests from specialists.</li></li></ul><li>Pre-Operative Planning for Ear Surgery Using Store-and-Forward TelemedicineJohn Kokesh M.D., A. Stewart Ferguson Ph.D., Chris Patricoski M.D.<br />The average difference was not statistically different between the two groups: 32 minutes for the telemedicine evaluation group and 35 minutes for the in-person evaluation group.<br />Comparison of surgical time (actual surgical time – estimated surgical time) for telehealth and non-telehealth cases. Values in the right half of the plot represent cases which took longer than planned (42% of telehealth cases and 47% of non-telehealth cases); values in the left half represent cases that took less time than planned (58% of telehealth cases and 53% of non-telehealth cases). <br />
  80. 80. ANMC: Access To Care<br />40<br />4,457 consult requests received at ANMC from Sep 2006 to Sep 2008<br />Median Time Spent by a Consultant Responding to a Case<br />ANMC provides same day turnaround time on 65% of all telehealth cases, and completes 84% of all telehealth cases by the next business day.<br />50% of all cases being turned around in one day are actually turned around in 1 hour.<br />Average response rate for “same day” turnaround is 2.5 hours.<br />Median Time per Case<br />
  81. 81. Dermatology CME Visits<br />41<br />Average case load was 2.6 cases/month prior to the CME visit. <br />This rose to 7.9 cases/month for each organization and was sustained for 18 months after the CME visit. <br />The net effect is that approximately 250 more patients are being seen per year<br />These 250 visits represent a savings in 80 man-years of waiting time.<br />
  82. 82. 42<br />For this case, rate the following statement:<br />Telemedicine helps me COMMUNICATE with a doctor. (n=2,672)<br />
  83. 83. Alaska rural facilities spent $12,000,000 in 2004 to recruit for 13 provider types.<br />The average cost to hire a provider is $38,000.<br />Tribal health organizations that include hospitals in their system expended $66,000 per new hire.<br />Rural health facilities average $42,575 to recruit each registered nurse<br />Alaska’s rural hospitals spent approximately four times the national average to hire providers.<br />Clinics spent approximately seven times the national average. <br />This is only magnified when considering the higher turnover rate.<br />Hiring Providers<br />43<br />
  84. 84. 44<br />For this case, rate the following statement:<br />Telemedicine makes my JOB MORE FUN. (n=1,897)<br /> “Each village trip I receive innumerable positive &quot;amazing&quot; comments from patients and parents about how wonderful this technology is for them. … I think the advanced cutting edge technology of telemedicine has actually kept my professional interest in staying within this region.”<br />
  85. 85. The Hand Switch<br />“I was able to see the problem - then the repaired normal condition - and discussed my problem - very informative!”<br />45<br />
  86. 86. 46<br />For this case, rate the following statement:<br />The telemedicine system played a role in EDUCATING THIS PATIENT. (n=2,605)<br />
  87. 87. Closing the BIG Loop<br />Review of 28,000 images<br />Selected 2,403 training images<br />75 different categories<br />30 educational modules<br />47<br />
  88. 88. PROVIDER Responses<br />Percentages of cases created to which the provider “Agreed” or “Strongly Agreed” with the statement.<br />
  89. 89. Consultation Model<br />49<br />Regional Hospital<br />Alaska Native Medical Center<br />Department<br />ConsultationRequest<br />Front Desk<br />Patient Registration<br />Case Managers<br />EHR<br />ConsultationComplete<br />Assistant Case Managers<br />Physicians<br />
  90. 90. Telehealth solutions offer much more than the simplified concept of remote consultation through access to remote specialists. A properly designed telehealth system can create great efficiencies through expert triage models, discharge planning, presurgical planning, post-surgical follow-up, care coordination, traveling providers, and other clinical workflow patterns.<br />Learning from Experience<br />50<br />
  91. 91. 51<br />
  92. 92. Thank You<br />AFHCAN, Alaska Native Tribal Health Consortium, Anchorage, AK<br />

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