Impact of Telehealth in Alaska

The Impact of Telehealthin AlaskaAn 8 Year Retrospective of the AFHCAN Project
Stewart Ferguson Ph.D., Director of Telehealth, ANTHC
John Kokesh MD, Chief of Otolaryngology Dept., ANMC
Chris Patricoski MD, AFHCAN Clinical Director, ANTHC
Phil Hofstetter, Director of Audiology, NSHC
Nathan Hogge, AFHCAN Senior Software Architect, ANTHC

1,420 miles (2400 km) (N-S)
2,400 miles (4000 km) (E-W)
ALASKA
More shoreline (33,900 miles or 56,500 km) than all Lower 48 states combined.
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.

Air travel required:
Provider
Patient

Case originated…

…Case received.

When Do You Need A Telemedicine Consultation?
Uncertain about the diagnosis.
Uncertain about the treatment.
Uncertain about the outcome; complications
Specialist participation earlier rather than later
“Expert Level Triage”

Store & Forward vs Real-Time Telehealth
Store & Forward
Real-Time (VtC)
Asynchronous Interaction
Documents & Images
Electronic Medical Records
Patient Education
Face-to-Face Interaction
Immediate Feedback
Remote
consultation
Radiology
Dermatology
Pathology
Oncology
Ophthalmology
Dental
Cardiology
ENT
GI
Pulmonary
Rheumatology
Psychology/ Psychiatry
Neurology
Speech therapy
Physical therapy
Clinical specialties for telemedicine
10

Store & Forward Telehealth
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.
Low bandwidth requirements
Static data – e.g. Vital signs
Static Images
Digital camera (megapixel)
Scans
Captured video images (ENT, Dental, Opthal., Naso.)
Video Clips – esp. from video devices
Temporal Data: ECG, stethoscope, tympanometer
Textual:
Health summaries
11

AFHCAN Telehealth
9 year Operational History
12,000 cases / year
Research and Production Telehealth System
Design  Installation  Training  Support  Marketing
12
Installed Customer base includes:
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

13
Telehealth Cases Created
Patients Involved in AFHCAN Telehealth

TELEHEALTH
Team
EXECUTIVE BOARD
CEO / Commanders
ANMC, VA, USCG, 3MDG, BACH, 354 MDG
STEERING BOARD
AFHCP Planning Board Chairman, AFHCP Project Officer, AFHCP Business Office
Director, ANMC Data Manager, and Clinical and Tribal Representatives
AFHCAN
Partners
Clinical
Training
APO
Technology
Business
OrganizationalChart“Communications”
Informatics

Ear Disease
Audiometer, Tympanometer, Video Otoscope
Heart Disease
ECG & Vital Signs Monitor
Respiratory Illness
Spirometer & Vital Signs Monitor
Trauma, Skin & Wound
Digital Camera
Dental Problems
Dental Camera
General
Scanner & Forms
Urgent Care / Critical Care
Video Camera
A Primary Care Tool
15

A User Interface Designed by Clinicians
Simplicity is key for Case Creation.
Minimize need for keyboard skills
Touchscreen
Color coded
16

A User Interface Designed by Clinicians
Rich Web Interface for Specialists
17

Champions
Service
Can
See potential
Create
Innovate
Nurture
Can’t
Sustain
Grow to large scale
Leave something behind
Guarantee of performance
Agreed upon expectations
Sustainable and scalable
Accountable
Independent of individuals
Requires support structure

Training Challenges
21
TRAINING NEW USERS
Each year, 35% of the users are using the AFHCAN system for the first time.
EMPOWERING EXPERIENCED USERS
Each year, 85% of the cases involve only “experienced” AFHCAN users.

Training
More than 20 manuals have been developed to augment the training and support provided by our staff.
AFHCAN provides training in many different areas such as:
Installation and cable management
Software administration for IT specialists
Clinical use of biomedical equipment
Clinical use of telemedicine software
Training Offerings:
Didactic classes
Web based training
Manuals
Ongoing monthly basis in Anchorage
On-site training in the regions
CMEs and CEUs available for many classes.
Classes include:
Desktop User
New User Training
Training Refresher
System Administrator
Train-the-Trainer Workshop
Non-Clinical Orientation
Cart Hardware Upgrade Procedure
Orientation to U.S. Telemedicine, for International Doctors

How can Telehealth reduce the cost of health care?
Physician’s surveyed at the point of care … on a per-case basis.
23

Medicaid StudyDecreased Travel = Cost Savings
24
Note: For every $1 spent by Medicaid on reimbursement, $7.95 is saved on travel costs.

25
Did viewing this telemedicine case/image affect PATIENT TRAVEL for diagnosis or treatment of this case (compared to a phone consult)?
It PREVENTED Patient Travel
It CAUSED Patient Travel
It had NO EFFECT

Impact of Telehealth onPreventing Patient Travel
26
Patient travel is prevented for almost 80% of all specialty consults.
Travel is prevented for about 20% of all primary care cases.
Responses were received to the travel question on 13,510 cases

Impact of Preventing Patient Travel
27
Travel savings generated by the use of AFHCAN telehealth amounts to approximately $14 million for 15,600 patients.
Annual travel savings, based on 2007 data, is approximately $3.5 million for 3,800 patients

Impact of Telehealth on Causing Patient Travel
28

Providing Care in the Patient’s Community
29

Traveling AudiologistTravel Avoidance = Cost Savings

Outcomes
About 69% of the patients seen needed something done (meds, surgery, ongoing monitoring) and 27% needed to be screened out.
Note: Percentages may not add to 100% due to multiple outcomes per case.

Three remote sites (Jan ‘09)
96 Patients imaged
66 patients  follow up in 12 mo.
30 patients have pathology that require an in-person visit with an ophthalmologist
11 with diabetic retinopathy
19 with additional pathology: Large optic cups, hard exudates, macular drusen, pseudophakia, ungradeable images with hx
IHS/JVN Alaska
Diabetic Retinopathy is the leading cause of new blindness among adults
Blindness due to diabetes can be eliminated by timely Dx and Tx

Expert Triage Model
33
80% of all consult prevent patient travel
Each year, 1 to 2 cases caused travel

Average Wait Time
35
Data courtesy of Phil Hofstetter

Waiting Times> 4 Months
36
Data courtesy of Phil Hofstetter

Improving Processes
37

38
Meeting “Standards of Care”
Post-surgical follow-up is difficult for patients from remote settings.
Telehealth provides ability to monitor and followup.
“Many simple problems, such as tympanostomy tube follow-up can be done with telemedicine without asking the patient to leave their village.“
ENT Specialist
Validated model
“Reverse Consult” empowers CHA/Ps and midlevels to respond to requests from specialists.

Pre-Operative Planning for Ear Surgery Using Store-and-Forward TelemedicineJohn Kokesh M.D., A. Stewart Ferguson Ph.D., Chris Patricoski M.D.
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.
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).

ANMC: Access To Care
40
4,457 consult requests received at ANMC from Sep 2006 to Sep 2008
Median Time Spent by a Consultant Responding to a Case
ANMC provides same day turnaround time on 65% of all telehealth cases, and completes 84% of all telehealth cases by the next business day.
50% of all cases being turned around in one day are actually turned around in 1 hour.
Average response rate for “same day” turnaround is 2.5 hours.
Median Time per Case

Dermatology CME Visits
41
Average case load was 2.6 cases/month prior to the CME visit.
This rose to 7.9 cases/month for each organization and was sustained for 18 months after the CME visit.
The net effect is that approximately 250 more patients are being seen per year
These 250 visits represent a savings in 80 man-years of waiting time.

42
For this case, rate the following statement:
Telemedicine helps me COMMUNICATE with a doctor. (n=2,672)

Alaska rural facilities spent $12,000,000 in 2004 to recruit for 13 provider types.
The average cost to hire a provider is $38,000.
Tribal health organizations that include hospitals in their system expended $66,000 per new hire.
Rural health facilities average $42,575 to recruit each registered nurse
Alaska’s rural hospitals spent approximately four times the national average to hire providers.
Clinics spent approximately seven times the national average.
This is only magnified when considering the higher turnover rate.
Hiring Providers
43

44
Telemedicine makes my JOB MORE FUN. (n=1,897)
“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.”

The Hand Switch
“I was able to see the problem - then the repaired normal condition - and discussed my problem - very informative!”
45

46
The telemedicine system played a role in EDUCATING THIS PATIENT. (n=2,605)

Closing the BIG Loop
Review of 28,000 images
Selected 2,403 training images
75 different categories
30 educational modules
47

PROVIDER Responses
Percentages of cases created to which the provider “Agreed” or “Strongly Agreed” with the statement.

Consultation Model
49
Regional Hospital
Alaska Native Medical Center
Department
ConsultationRequest
Front Desk
Patient Registration
Case Managers
EHR
ConsultationComplete
Assistant Case Managers
Physicians

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.
Learning from Experience
50

Thank You
AFHCAN, Alaska Native Tribal Health Consortium, Anchorage, AK

Impact of Telehealth in Alaska

by Health Informatics New Zealand on Dec 10, 2009

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Impact of Telehealth in Alaska — Presentation Transcript

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