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Outcomes and Impacts of Telehealth in Alaska: An 8 Year Retrospective
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Outcomes and Impacts of Telehealth in Alaska: An 8 Year Retrospective



Stewart Ferguson, PhD ...

Stewart Ferguson, PhD
Acting CIO, Alaska Native Tribal Health Consortium and Director, Alaska Federal Health Care Access Network (AFHCAN)

John Kokesh, MD
Medical Director, Department of Otolaryngology, Alaska Native Medical Center

(4/11/10, Illott, 2.15)



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  • Filet fillets
  • This slide demonstrates the complexity of the processes that have to be developed to make this initiative successful, and there are critical steps in every phase.Beginning with phase 3 this summer, after selecting a regional partner we plan to begin working on a workflow analysis within the organization, creating a process for electronic referral and educating/training on the process of sending electronic referrals that has been created. The organization will eventually be sending electronic referral cases to 4 specific ANMC Departments (advance) that are ready to accept electronic referrals, because as part of phase 2 of this project they will have a process in place with customized referral forms designed. (advance)With all parties on the same level and ready to being the process, we plan to test the process before we actually go live. Once all parties satisfied with the tests, then we will begin the actual process with an official go live date. During the first 30 days will being supporting the partners and doing ongoing process analysis. Our goal would be within 30 days that we will meet will all parties involved and do a formal process evaluation to gather feedback and suggestions for improvement. The improved process will be documented and utilized as a resource moving forward. With that in place, we will move to take on 2 additional regional partners, with the same 4 anmc departments utilizing the same model of workflow testing and go live cycle. The 3 partners that we begin this project with will be representative of the variety of organizational structures and size in our healthcare system. Once we have 3 Regional partners electronically referring to 4 ANMC departments we will have a successful process that will then allow us to continue to simultaneously add additional anmc departments and regional partners; with the goal of a statewide electronic referral system. And, We would like to continue to use this forum to share our progress with this initiative.
  • So we are in an excellent position to compare and contrast, from a coding and billing standpoint, these two different, and often competing means of evaluating and treating what is essentially the same patient population with the same diseases.
  • For the two diagnoses under consideration, ETD and TM perforation, there were over 2000 telemedicine and almost 7000 in person encounters to compare.

Outcomes and Impacts of Telehealth in Alaska: An 8 Year Retrospective Presentation Transcript

  • 1. Outcomes and Impacts of Telehealth in AlaskaAn 8 Year Retrospective
    Stewart Ferguson Ph.D.
    Acting CIO, ANTHC
    Director of Telehealth, ANTHC
    John Kokesh MD
    Chief, Dept. of Otolaryngology
    Alaska Native Medical Center
  • 2. 2
  • 3. 3
  • 4. 4
  • 5. 5
    Why is Dipnetting like Telehealth?
    Talk about Efficient !!
    Requires New Tools
    Increased Satisfaction
    Requires Process Redesign
    One Word: Licensure
    Requires a Collaborative Environment
    Send filets to friends (store and forward)
    Not Taught in Med School
    Better, Sooner, More Convenient
  • 6. 6
    1st in land mass
    1,420 miles (N-S)
    2,400 miles (E-W)
    33,900 miles of shoreline
    More than all of the contiguous states combined.
    National Travel and Safety Board (NTSB) reported 436 commuter aircraft accidents in Alaska from1990-2004 (2.8 accidents a month) - accounting for 36% of all commuter aircraft accidents in the US.
    • 47th in road miles
    • 7. 75% Alaskan communities unconnected by a road to a hospital.
    • 8. 25 of these have no airport.
    • 9. Population density is 1.1 persons/mile2
    • 10. 70 times smaller than the national average.
    49% of all physicians in Alaska are primary care physicians (2002 data)
    U.S. average is 28%
    Alaska is 48th in “doctors to residents” ratio
    65% are located in Anchorage
    Shortages in many specialties
    • 59% of the state’s residents are in medically underserved areas.
    Historically, Alaskan health care has incorporated a public health mission and primary care focus, and is less reliant on specialty acute care than other parts of the country.
  • 11.
  • 12.
  • 13. Simple problem
    Difficult access
  • 14. Air travel required:
  • 15. Poor access leads to poor clinical outcomes
  • 16. Case originated…
  • 17. …Case received.
  • 18. Hearing Aid Clearance
  • 19. Post cochlear implant rehab
  • 20. Image of facial lesion
  • 21.
  • 22. 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”
    To improve access to health care for federal beneficiaries in Alaska through sustainable telehealth systems
  • 24. 10 year Operational History
    20,000 cases / year
    Whole Telehealth Solution
    Design  Manufacturing  Deployment  Installation  Training  Support  Marketing
    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)
    Other states and countries
    AFHCAN Telehealth
  • 25. Rich, Minimal Data Needs
  • 26. 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
    Scanner & Forms
    Designing A Primary Care Tool
  • 27. Design Evolution
    Base Cart include:
    Metal Frame
    Isolated Power System
    CPU and LCD Touchscreen
    Expansion Ports for USB, RS232, Video In/Out, External Display
    Currently Supported Peripherals include:
    Video Otoscope
    Digital Camera
    Video Conferencing
    Dental Camera
    Vital Signs Monitor
  • 28. A User Interface Designed by Users
  • 29.
  • 30. $10,000 USD/month
  • 31. Store & Forward vs Real-Time Telehealth
    Store & Forward
    Real-Time (VtC)
    • Asynchronous Interaction
    • 32. Documents & Images
    • 33. Electronic Medical Records
    • 34. Patient Education
    • 35. Face-to-Face Interaction
    • 36. Immediate Feedback
    • Radiology
    • 37. Dermatology
    • 38. Pathology
    • 39. Oncology
    • 40. Ophthalmology
    • 41. Dental
    • 42. Cardiology
    • 43. ENT
    • 44. GI
    • 45. Pulmonary
    • 46. Rheumatology
    • 47. Psychology/ Psychiatry
    • 48. Neurology
    • 49. Speech therapy
    • 50. Physical therapy
    Clinical specialties for telemedicine
  • 51. Summary of Key Design Issues
    Data Ownership
    Security – Encryption, Firewall Traversal, Signatures
    Groups vs Providers
    Local vs Global Users / Providers
    Consultants vs Clinical Users
    • Real vs Test vs Sensitive Cases
    • 52. High Speed Scanning
    • 53. Customizable Forms
    • 54. Interfaces to external systems (EHR, A/D)
    • 55. Satellite Delays
    • 56. Online vs Offline capability
    • 57. Multilanguage support
  • 58. OUTCOMES
    ATHS (Alaska Tribal Health System)
    1/1/2001 to 8/31/2010
    (82,041 Cases)
  • 59. ATHS (Alaska Tribal Health System) (1/1/2001 to 8/31/2010)
  • 60. 32
    How can Telehealth reduce the cost of health care?
    Physician’s surveyed at the point of care … on a per-case basis.
  • 61. 2002 Medicaid Expenditures
    $629.9 million
  • 62. Medicaid Study: 2002Decreased Travel = Cost Savings
    Note: For every $1 spent by Medicaid on reimbursement, $7.95 is saved on travel costs.
  • 63. Medicaid Study: 2003-2009Decreased Travel = Cost Savings
    Note: For every $1 spent by Medicaid on reimbursement, $10.54 is saved on travel costs.
  • 64. We only assume patients travel to nearest region
  • 65. Lost Work Days/ School Days
    Since 2003, telehealth prevented an estimated 4,777 lost days at work, and a total of 1,444 lost days at school for the patients in this study.
  • 66. 38
    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
    • 67. It CAUSED Patient Travel
    • 68. It had NO EFFECT
  • ATHS (Alaska Tribal Health System) (1/1/2001 to 8/31/2010)
  • 69. $5 Million estimated travel savings for 2010
    ATHS (Alaska Tribal Health System) (1/1/2001 to 8/31/2010)
  • 70. ATHS (Alaska Tribal Health System) (1/1/2001 to 8/31/2010)
  • 71. Something Different
  • 72. 43
  • 73. 44
  • 74. 45
  • 75. 46
  • 76. 47
  • 77. 48
    Providing Care in the Patient’s Community
  • 78. Disparity of care
  • 79.
  • 80.
  • 81. Extending Careto the Village
  • 82. Note1: 1,987 patients
    Note2: Percentages may not add to 100% due to multiple outcomes per case.
    About 72% of the patients seen needed something done (meds, surgery, ongoing monitoring) and 26% needed to be screened out.
  • 83. Diabetes Management & JVN
  • 84. Diabetic Retinopathy is the leading cause of new blindness among adults
    Blindness due to diabetes can be eliminated by timely Dx and Tx
    ~ 4% of AI/AN’s with DM need laser tx to prevent vision loss
    Diabetic Retinopathy
  • 85. 15% Increase
    Portable JVN implemented
    25% Decrease
    Joslin Vision Network (JVN)Portable JVN Pilot
    Deployment of the IHS-JVN in Alaska using a portable platform reversed a seven year decline in rates for the state
  • 86. 57
    Improving Access
    Greater Efficiency of Existing Resources
  • 87. Available Appointments
    Data courtesy of Phil Hofstetter
  • 88. Average Wait Time
    Data courtesy of Phil Hofstetter
  • 89. Telehealth Impact on Extended Waiting Times (> 4 months)
    Data courtesy of Phil Hofstetter
  • 90. Access
    Data courtesy of Phil Hofstetter
  • 91. Expert Triage Model
    80% of all consult prevent patient travel
    Each year, 1 to 2 cases caused travel
  • 92. 63
    Improving Processes
  • 93. Ear tube follow up studyThe Value Proposition
    254 sets of tubes placed at ANMC in 2000
    1,000 follow up appointments needed in 12 month period
    Many of these patients from remote areas
  • 94. To determine if video otoscope still images (640 x 480 pixel resolution) of the tympanic membrane following surgical placement of tympanostomy tubes are comparable to an in-person microscopic examination.
    Blinded Study
  • 95. High level of agreement
    Correlation between in person exam and telemedicine exam good to excellent
    Telemedicine can be used to do routine ear tube follow up
    Make available several hundred appointments per year
    Kokesh J, Ferguson AS, Patricoski C, Koller K, Zwack G, Provost E, Holck P. “Digital images for postsurgical follow-up of tympanostomy tubes in remote Alaska”. Otolaryngology-Head and Neck Surgery, 139:87-93, 2008.
    Patricoski C, Kokesh J, Ferguson AS, Koller K, Zwack G, Provost E, Holck P. “A Comparison of In-Person Examination and Video Otoscope Imaging for Tympanostomy Tube Follow-Up”. Telemedicine Journal and e-Health, 9(4):331-344, 2003.
  • 96. 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)
  • 97. Gaining Efficiencies
    Median Time Spent by a Consultant Responding to a Case
  • 98. 69
    Referral Management
    Or why I hate faxes
  • 99. Large Organization A
    Large Organization B
    Small Organization C
    Small Organization D
    Alaska Native Medical Center (ANMC)
  • 100. All clinics fit somewhere into this pattern with their process
    Case Manager
    Case Manager
  • 101. Poor quality
    No record of transmission, receipt, activity
    Get lost, mixed up, resorted
    Cannot enforce and rules (e.g. field level)
    Wrong numbers!
    Why I hate faxes …
    Faxed information comes in “batches” and may be incomplete.
    Each Department has different “forms” and information needs.
    Manual intervention and phone calls are the rule of the day.
  • 102. Large Organization A
    Large Organization B
    Small Organization C
    Small Organization D
    Alaska Native Medical Center (ANMC)
  • 103.
    • Forms Designer (used by Clinicians!)
    • 104. Rich form element types
    • 105. Integrated database fields
    • 106. Community driven template library
    • 107. Supports clinical pathways
    • 108. Full support for multiuser entry and versioning
  • 109. Regional processes need to be designed & tested
    ANMC Departmental processes need to be designed & tested
    Regional  ANMC communication needs to be tested &validated
    Alaska Tribal Health System
    Department 1
    Regional Hospital 1
    Department 2
    Regional Hospital 2
    Department 3
    Regional Hospital 3
    Department 4
    Regional Hospital 4
    Department N
    Regional Hospital N
    N2 Connections
    2*N Unique Processes
  • 110. Large Organization A
    Large Organization B
    Step 2
    Step 3
    Small Organization C
    Step 3
    Small Organization D
    Step 1
    Alaska Native Medical Center (ANMC)
    Step 3
  • 111. ANMC “Internal Use” Cases
    Note: Cases are counted once for each department that is involved in that case. This leads to multiple counts when a case hits multiple departments.
  • 112. AFHCAN Benefits
    Route information to the right location
    Halt the process if information is missing
    Keep cost and burden of information verification at the front desk level
    Notify other users
    … of an AFHCAN case at any point in the referral path
    See the status of a case
    Who has it and where is it?
    Key Process Indicators
    Workload, turnaround time, creation time, delays in process, etc
  • 113. 79
    Lessons Learned
    • Response rate depends on “completeness” of information.
    • 114. Unstructured data creates miscommunication and creates a reliance on “know how”.
  • 80
    Improving Relationships
  • 115. 81
    36,383 Responses
  • 116. 82
    How satisfied were you with the use of the telemedicine technology?
    Willing to have a telemedicine exam for follow-up?
    Overall Satisfaction With This Visit
    How well did the telemedicine technology help you understand your problem?
  • 117. “I was able to see the problem - then the repaired normal condition … and discussed my problem - very informative!”
    “I liked to see with my own eyes the inside of my ear!”
  • 118. 20% of all specialty consultations are turned around in 60 minutes.
    50%-60% are turned around in the same day.
    70%-80% are turned around within 24 hours.
  • 119. It’s all about relationships …
    Almost 250 more patients are being seen per year, a savings in 80 man-years of waiting time.
    2.6 cases/month
    7.9 cases/month
  • 120. 86
    For this case, rate the following statement:
    Telemedicine makes my JOB MORE FUN. (n=4,787)
  • 121. 87
    Hiring Providers
    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.
  • 122. 88
    Why you need a “System”
  • 123. What price telemedicine?(Another word about incentives)
  • 124. The most common diagnoses are 381.81 (dysfunction of eustachean tube) and 384.2 (perforation of tympanic membrane) – accounting for 2,195 billable telehealth events and 6,988 billable “in person” events.
  • 125. For the same clinical problem and category of patient (consult, established) charges generated by S&F telemedicine encounters were 45% lower than for in person encounters.
  • 126. S&F telemedicine reimburses less than in person encounters
    Provider would need to “make up the difference” in increased volume and productivity
    Reimbursement model undervalues system benefits from S&F telemedicine
    • Cost savings (travel, loss of time from work)
    • 127. Improved access for care
    • 128. Addressing disparity in care
    • 129. Clinical outcomes (?)
    Summary Points - Under Current Reimbursement System
  • 130. 93
    Product Development
    A word about software …
  • 131. 94
    Program Development
    It’s not just about training …
  • 132. 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
    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
  • 133. Evolved from a training focus to a bigger picture view that incorporates program development and education
    Using education as a driver for systemic change
    Assisting organizations with clinical workflow design, program evaluation & adoption
    Fostering relationships between referring healthcare providers and consultants
    Training  Program Development
  • 134. Closing the BIG Loop
    Review of 28,000 images
    Selected 2,403 training images
    75 different categories
    30 educational modules
  • 135. Connecting the Enterprise
    Where does Telehealth fit into the
    “Health Information Exchange?”
  • 136. Health Information Exchange (HIE)and the role of telehealth …
    The goal of HIE is to facilitate access to and retrieval of clinical data to provide safer, more timely, efficient, effective, equitable, patient-centered care.
    Health Information Exchange (HIE) The mobilization of healthcare information electronically across organizations within a region, community or hospital system.
    “Classic” EHR/ EMR
  • 137. WHAT IS HOT
    AFHCAN’s success in the past has been by ourselves
    AFHCAN server
    AFHCAN server
    AFHCAN’s future success will be based on how well our system can work with others
    [your system]
  • 138. 101
    Nationwide Health Information Network
  • 139. IS 01: Electronic Health Record (EHR) Laboratory Results Reporting
    IS 02: Biosurveillance
    IS 03: Consumer Empowerment
    IS 04: Emergency Responder Electronic Health Record (ER-EHR)
    IS 05: Consumer Empowerment and Access to Clinical Information via Media
    IS 06: Quality
    IS 07: Medication Management
    IS 08: Personalized Healthcare
    IS 09: Consultations and Transfers of Care
    IS 10: Immunizations and Response Management
    IS 11: Public Health Case Reporting
    IS 12: Patient – Provider Secure Messaging
    IS 77: Remote Monitoring
    Nationwide Health Information Network (NHIN)
    “Network of Networks”
    being developed to provide a secure, nationwide, interoperable health information infrastructure that will connect providers, consumers, and others involved in supporting health and healthcare
    The Health Information Security and Privacy Collaboration
    Healthcare Information Technology Standards Panel
    Certification Commission for Healthcare Information Technology
  • 140. Defined Interfaces
    C32 – Summary Document Using HL7 CCD
    May include administrative (e.g., registration, demographics, insurance, etc.) and clinical (problem list, medication list, allergies, test results, etc) information
    C48 – Encounter Document
    AFHCAN will be going live with C32 interfaces to EHRs statewide later in 2010.
    Supports the process of sending patient encounter data (excluding laboratory and radiology)
    C74 – Remote Monitoring Observation
    Medical information collected by remote monitoring management systems from monitoring devices and/or device intermediaries
    C84 – Consult and History & physical note
    Support the exchange of information from a consulting provider to a referring provider; and may also be used to provide background information from a referring provider to a consulting provider
  • 141. WHAT IS HOT
    Enterprise Remote Patient Monitoring (RPM)
    • Centralized Call Center for multiple organizations
    • 142. Proposal to fully integrate with EHR
    • 143. Seamless updates on patient demographics and provider contact info
  • 2003-2009
    Blending Specialties
    Remote Consultation
    Disease Mgmt
    Behavioral Health
    Store & Forward
    Remote Monitoring
  • 144. 2010 
    Remote Consultation
    Disease Mgmt
    Behavioral Health
    Store & Forward
    Remote Monitoring
  • 145. 107
    A Changing Landscape
    Traditional Devices
    + New Connectivity
    + New Messaging
  • 146. WHAT IS HOT
  • 147. WHAT IS HOT
    Connected Health
    EMR, PHR, HIE, MPI, PACS, Home Health
    Standards, NHIN, Meaningful use
    Real-time blended with S&F
    Work Flow
  • 148. 110
  • 149. 111
  • 150. 112
    American Telemedicine Association
    2011 Mid-Year MeetingSeptember 19-21, 2011Anchorage, AK
  • 151. Thank You
    Stewart Ferguson, PhD
    Alaska Federal Health Care Access Network (AFHCAN)
    Alaska Native Tribal Health Consortium
    4000 Ambassador Drive
    Anchorage, AK 99508
    (907) 729-2262
    John Kokesh, MD
    Department of Otolaryngology
    Alaska Native Medical Center
    4315 Diplomacy Drive
    Anchorage, AK 99508
    (907) 729-1416
    AFHCAN, Alaska Native Tribal Health Consortium, Anchorage, AK