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<br />
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. 75% of Alaskan communities are unconnected by a road to a hospital.
5. 25% Alaskans (46% of Alaskan Natives) live in communities of less than 1000 people.
6. Population density is 70X smaller than the national average.
7. 49% of all physicians in Alaska are primary care physicians compared to U.S. average of 28%
8. Alaska is 48th in “doctors to residents” ratio. 65% are located in Anchorage.</li></li></ul><li>
10. Air travel required:<br />Provider<br />Patient <br />
11. Case originated…<br />
12. …Case received.<br />
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. Store & Forward vs Real-Time Telehealth<br />Store & Forward<br />Real-Time (VtC)<br /><ul><li>Asynchronous Interaction
33. Physical therapy</li></ul>Clinical specialties for telemedicine<br />10<br />
34. Store & Forward Telehealth<br /><ul><li>Asynchronous.
35. Can create a case “on the run.”
36. Doctor can respond when available.
37. Many consults are not critical.
38. It is needed as a communication tool.
39. Fits with present model.
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. 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:
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. A User Interface Designed by Clinicians<br />Rich Web Interface for Specialists<br />17<br />
53. 18<br />
54. 19<br />
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. Agreed upon expectations
57. Sustainable and scalable
59. Independent of individuals
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. 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. 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. 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. 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. It CAUSED Patient Travel
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. 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. Impact of Telehealth on Causing Patient Travel<br />28<br />
69. Providing Care in the Patient’s Community<br />29<br />
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. 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. Expert Triage Model<br />33<br />80% of all consult prevent patient travel<br />Each year, 1 to 2 cases caused travel <br />
75. Average Wait Time<br />35<br />Data courtesy of Phil Hofstetter<br />
76. Waiting Times> 4 Months<br />36<br />Data courtesy of Phil Hofstetter<br />
77. Improving Processes<br />37<br />
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. “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. 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. 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. 42<br />For this case, rate the following statement:<br />Telemedicine helps me COMMUNICATE with a doctor. (n=2,672)<br />
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. 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 "amazing" 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. 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. 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. 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. PROVIDER Responses<br />Percentages of cases created to which the provider “Agreed” or “Strongly Agreed” with the statement.<br />
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 />