Outcomes and Impacts of Telehealth in AlaskaAn 8 Year Retrospective<br />Stewart Ferguson Ph.D.<br />Acting CIO, ANTHC<br ...
2<br />
3<br />
4<br />
5<br />Why is Dipnetting like Telehealth?<br />Talk about Efficient !!<br />Requires New Tools<br />Increased Satisfaction...
6<br />ALASKA<br />1st in land mass<br />1,420 miles (N-S)<br />2,400 miles (E-W)<br />33,900 miles of shoreline<br />More...
75% Alaskan communities unconnected by a road to a hospital.
25 of these have no airport.
Population density is 1.1 persons/mile2
70 times smaller than the national average.</li></li></ul><li>ALASKA’s PHYSICIANS<br />49% of all physicians in Alaska are...
Simple problem<br />Difficult access<br />
Air travel required:<br />Provider<br />Patient <br />
Poor access leads to poor clinical outcomes <br />
Case originated…<br />
…Case received.<br />
Hearing Aid Clearance<br />
Post cochlear implant rehab<br />
Image of  facial lesion<br />
When Do You Need A Telemedicine Consultation?<br />Uncertain about the diagnosis.<br />Uncertain about the treatment.<br /...
AFHCAN MISSION<br />To improve access to health care for federal beneficiaries in Alaska through sustainable telehealth sy...
10 year Operational History<br />20,000 cases / year<br />Whole Telehealth Solution<br />Design  Manufacturing  Deployme...
Rich, Minimal Data Needs<br />22<br />
Ear Disease<br />Audiometer, Tympanometer, Video Otoscope<br />Heart Disease<br />ECG & Vital Signs Monitor<br />Respirato...
Design Evolution<br />Base Cart include:<br />Metal Frame<br />Isolated Power System<br />CPU and LCD Touchscreen<br />Exp...
A User Interface Designed by Users<br />25<br />
$10,000 USD/month<br />27<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 />28<br />
Summary of Key Design Issues<br />Data Ownership<br />Security – Encryption, Firewall Traversal, Signatures<br />Groups vs...
High Speed Scanning
Customizable Forms
Interfaces to external systems (EHR, A/D)
Satellite Delays
Online vs Offline capability
Multilanguage support</li></ul>29<br />
OUTCOMES<br />ATHS (Alaska Tribal Health System)<br />1/1/2001 to 8/31/2010<br />(82,041 Cases)<br />
ATHS (Alaska Tribal Health System) (1/1/2001 to 8/31/2010)<br />31<br />
32<br />How can Telehealth reduce the cost of health care?<br />Physician’s surveyed at the point of care … on a per-case ...
2002 Medicaid Expenditures<br />$629.9 million<br />
Medicaid Study: 2002Decreased Travel = Cost Savings<br />34<br />Note:  For every $1 spent by Medicaid on reimbursement, $...
Medicaid Study: 2003-2009Decreased Travel = Cost Savings<br />35<br />Note:  For every $1 spent by Medicaid on reimburseme...
We only assume patients travel to nearest region<br />
Lost Work Days/ School Days<br />Since 2003, telehealth prevented an estimated 4,777 lost days at work, and a total of 1,4...
38<br />Did viewing this telemedicine case/image affect PATIENT TRAVEL for diagnosis or treatment of this case (compared t...
  It CAUSED Patient Travel
  It had NO EFFECT</li></li></ul><li>ATHS (Alaska Tribal Health System) (1/1/2001 to 8/31/2010)<br />39<br />
$5 Million estimated travel savings for 2010 <br />ATHS (Alaska Tribal Health System) (1/1/2001 to 8/31/2010)<br />40<br />
ATHS (Alaska Tribal Health System) (1/1/2001 to 8/31/2010)<br />41<br />
Something Different<br />
43<br />
44<br />
45<br />
46<br />
47<br />
48<br />Providing Care in the Patient’s Community<br />
Disparity of care<br />
Extending Careto the Village<br />
Note1: 1,987 patients<br />Note2: Percentages may not add to 100% due to multiple outcomes per case.<br />Outcomes<br />Ab...
Diabetes Management & JVN<br />54<br />PLAN<br />ACT<br />DO<br />STUDY<br />
Diabetic Retinopathy is the leading cause of new blindness among adults<br />Blindness due to diabetes can be eliminated b...
15% Increase<br />Portable JVN implemented<br />25% Decrease<br />Joslin Vision Network (JVN)Portable JVN Pilot<br />Deplo...
57<br />Improving Access<br />Greater Efficiency of Existing Resources<br />
Available Appointments<br />58<br />Data courtesy of Phil Hofstetter<br />
Average Wait Time<br />59<br />Data courtesy of Phil Hofstetter<br />
Telehealth Impact on Extended Waiting Times (> 4 months)<br />60<br />Data courtesy of Phil Hofstetter<br />
Access<br />Data courtesy of Phil Hofstetter<br />
Expert Triage Model<br />62<br />80% of all consult prevent patient travel<br />Each year, 1 to 2 cases caused travel <br />
63<br />Improving Processes<br />
Ear tube follow up studyThe Value Proposition<br />64<br />254 sets of tubes placed at ANMC in 2000<br />1,000 follow up a...
To determine if video otoscope still images (640 x 480 pixel resolution) of the tympanic membrane following surgical place...
High level of agreement<br />Correlation between in person exam and telemedicine exam good to excellent<br />Telemedicine ...
Pre-Operative Planning for Ear Surgery Using Store-and-Forward TelemedicineJohn Kokesh M.D., A. Stewart Ferguson Ph.D., Ch...
Gaining Efficiencies<br />68<br />Median Time Spent by a Consultant Responding to a Case<br />
69<br />Referral Management<br />Or why I hate faxes<br />
Large Organization A<br />Large Organization B<br />Small Organization C<br />Small Organization D<br />Alaska Native Medi...
All clinics fit somewhere into this pattern with their process<br />Case Manager<br />Physician<br />Faxed <br />Referral<...
Poor quality<br />No record of transmission, receipt, activity<br />Uneditable<br />Get lost, mixed up, resorted<br />Cann...
Large Organization A<br />Large Organization B<br />Small Organization C<br />Small Organization D<br />Alaska Native Medi...
<ul><li>Forms Designer (used by Clinicians!)
Rich form element types
Integrated database fields
Community driven template library
Supports clinical pathways
Full support for multiuser entry and versioning</li></ul>WHAT IS HOT<br />FORMS<br />
Regional processes need to be designed & tested<br />ANMC Departmental processes need to be designed & tested<br />Regiona...
Large Organization A<br />Large Organization B<br />Step 2<br />Step 3<br />Small Organization C<br />Step 3<br />Small Or...
ANMC “Internal Use” Cases<br />Note:  Cases are counted once for each department that is involved in that case.  This lead...
AFHCAN Benefits<br />Route information to the right location<br />Halt the process if information is missing<br />Keep cos...
79<br />Lessons Learned<br /><ul><li>Response rate depends on “completeness” of information.
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Outcomes and Impacts of Telehealth in Alaska: An 8 Year Retrospective

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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

    1. 1. Outcomes and Impacts of Telehealth in AlaskaAn 8 Year Retrospective<br />Stewart Ferguson Ph.D.<br />Acting CIO, ANTHC<br />Director of Telehealth, ANTHC<br />John Kokesh MD<br />Chief, Dept. of Otolaryngology<br />Alaska Native Medical Center<br />
    2. 2. 2<br />
    3. 3. 3<br />
    4. 4. 4<br />
    5. 5. 5<br />Why is Dipnetting like Telehealth?<br />Talk about Efficient !!<br />Requires New Tools<br />Increased Satisfaction<br />Requires Process Redesign<br />One Word: Licensure<br />Requires a Collaborative Environment<br />Send filets to friends (store and forward)<br />Not Taught in Med School<br />Better, Sooner, More Convenient<br />
    6. 6. 6<br />ALASKA<br />1st in land mass<br />1,420 miles (N-S)<br />2,400 miles (E-W)<br />33,900 miles of shoreline<br />More than all of the contiguous states combined.<br />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. <br /><ul><li>47th in road miles
    7. 7. 75% Alaskan communities unconnected by a road to a hospital.
    8. 8. 25 of these have no airport.
    9. 9. Population density is 1.1 persons/mile2
    10. 10. 70 times smaller than the national average.</li></li></ul><li>ALASKA’s PHYSICIANS<br />49% of all physicians in Alaska are primary care physicians (2002 data)<br />U.S. average is 28%<br />Alaska is 48th in “doctors to residents” ratio<br />65% are located in Anchorage<br />Shortages in many specialties<br /><ul><li>59% of the state’s residents are in medically underserved areas.</li></ul>7<br /> 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. <br />
    11. 11.
    12. 12.
    13. 13. Simple problem<br />Difficult access<br />
    14. 14. Air travel required:<br />Provider<br />Patient <br />
    15. 15. Poor access leads to poor clinical outcomes <br />
    16. 16. Case originated…<br />
    17. 17. …Case received.<br />
    18. 18. Hearing Aid Clearance<br />
    19. 19. Post cochlear implant rehab<br />
    20. 20. Image of facial lesion<br />
    21. 21.
    22. 22. 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 />
    23. 23. AFHCAN MISSION<br />To improve access to health care for federal beneficiaries in Alaska through sustainable telehealth systems<br />Alaska<br />Federal<br />Health<br />Care<br />Access<br />Network<br />
    24. 24. 10 year Operational History<br />20,000 cases / year<br />Whole Telehealth Solution<br />Design  Manufacturing  Deployment  Installation  Training  Support  Marketing<br />Installed Customer base includes:<br />Alaska: 248 sites, 44 organizations<br />37 Tribal organizations<br />US Army sites (6) & US Air Force bases (3)<br />State of Alaska Public Health Nursing (26)<br />Other states and countries<br />AFHCAN Telehealth<br />21<br />
    25. 25. Rich, Minimal Data Needs<br />22<br />
    26. 26. 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 />Designing A Primary Care Tool<br />23<br />
    27. 27. Design Evolution<br />Base Cart include:<br />Metal Frame<br />Isolated Power System<br />CPU and LCD Touchscreen<br />Expansion Ports for USB, RS232, Video In/Out, External Display<br />Currently Supported Peripherals include:<br />Video Otoscope<br />Digital Camera<br />Scanner<br />Video Conferencing<br />ECG<br />Spirometer<br />Tympanometer<br />Audiometer<br />Dental Camera<br />Vital Signs Monitor<br />Stethoscope<br />
    28. 28. A User Interface Designed by Users<br />25<br />
    29. 29.
    30. 30. $10,000 USD/month<br />27<br />
    31. 31. Store & Forward vs Real-Time Telehealth<br />Store & Forward<br />Real-Time (VtC)<br /><ul><li>Asynchronous Interaction
    32. 32. Documents & Images
    33. 33. Electronic Medical Records
    34. 34. Patient Education
    35. 35. Face-to-Face Interaction
    36. 36. Immediate Feedback</li></ul>Remote<br />consultation<br /><ul><li>Radiology
    37. 37. Dermatology
    38. 38. Pathology
    39. 39. Oncology
    40. 40. Ophthalmology
    41. 41. Dental
    42. 42. Cardiology
    43. 43. ENT
    44. 44. GI
    45. 45. Pulmonary
    46. 46. Rheumatology
    47. 47. Psychology/ Psychiatry
    48. 48. Neurology
    49. 49. Speech therapy
    50. 50. Physical therapy</li></ul>Clinical specialties for telemedicine<br />28<br />
    51. 51. Summary of Key Design Issues<br />Data Ownership<br />Security – Encryption, Firewall Traversal, Signatures<br />Groups vs Providers<br />Local vs Global Users / Providers<br />Consultants vs Clinical Users<br /><ul><li>Real vs Test vs Sensitive Cases
    52. 52. High Speed Scanning
    53. 53. Customizable Forms
    54. 54. Interfaces to external systems (EHR, A/D)
    55. 55. Satellite Delays
    56. 56. Online vs Offline capability
    57. 57. Multilanguage support</li></ul>29<br />
    58. 58. OUTCOMES<br />ATHS (Alaska Tribal Health System)<br />1/1/2001 to 8/31/2010<br />(82,041 Cases)<br />
    59. 59. ATHS (Alaska Tribal Health System) (1/1/2001 to 8/31/2010)<br />31<br />
    60. 60. 32<br />How can Telehealth reduce the cost of health care?<br />Physician’s surveyed at the point of care … on a per-case basis.<br />
    61. 61. 2002 Medicaid Expenditures<br />$629.9 million<br />
    62. 62. Medicaid Study: 2002Decreased Travel = Cost Savings<br />34<br />Note: For every $1 spent by Medicaid on reimbursement, $7.95 is saved on travel costs.<br />
    63. 63. Medicaid Study: 2003-2009Decreased Travel = Cost Savings<br />35<br />Note: For every $1 spent by Medicaid on reimbursement, $10.54 is saved on travel costs.<br />
    64. 64. We only assume patients travel to nearest region<br />
    65. 65. Lost Work Days/ School Days<br />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.<br />
    66. 66. 38<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
    67. 67. It CAUSED Patient Travel
    68. 68. It had NO EFFECT</li></li></ul><li>ATHS (Alaska Tribal Health System) (1/1/2001 to 8/31/2010)<br />39<br />
    69. 69. $5 Million estimated travel savings for 2010 <br />ATHS (Alaska Tribal Health System) (1/1/2001 to 8/31/2010)<br />40<br />
    70. 70. ATHS (Alaska Tribal Health System) (1/1/2001 to 8/31/2010)<br />41<br />
    71. 71. Something Different<br />
    72. 72. 43<br />
    73. 73. 44<br />
    74. 74. 45<br />
    75. 75. 46<br />
    76. 76. 47<br />
    77. 77. 48<br />Providing Care in the Patient’s Community<br />
    78. 78. Disparity of care<br />
    79. 79.
    80. 80.
    81. 81. Extending Careto the Village<br />
    82. 82. Note1: 1,987 patients<br />Note2: Percentages may not add to 100% due to multiple outcomes per case.<br />Outcomes<br />About 72% of the patients seen needed something done (meds, surgery, ongoing monitoring) and 26% needed to be screened out.<br />
    83. 83. Diabetes Management & JVN<br />54<br />PLAN<br />ACT<br />DO<br />STUDY<br />
    84. 84. 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 />~ 4% of AI/AN’s with DM need laser tx to prevent vision loss<br />Diabetic Retinopathy <br />
    85. 85. 15% Increase<br />Portable JVN implemented<br />25% Decrease<br />Joslin Vision Network (JVN)Portable JVN Pilot<br />Deployment of the IHS-JVN in Alaska using a portable platform reversed a seven year decline in rates for the state<br />
    86. 86. 57<br />Improving Access<br />Greater Efficiency of Existing Resources<br />
    87. 87. Available Appointments<br />58<br />Data courtesy of Phil Hofstetter<br />
    88. 88. Average Wait Time<br />59<br />Data courtesy of Phil Hofstetter<br />
    89. 89. Telehealth Impact on Extended Waiting Times (> 4 months)<br />60<br />Data courtesy of Phil Hofstetter<br />
    90. 90. Access<br />Data courtesy of Phil Hofstetter<br />
    91. 91. Expert Triage Model<br />62<br />80% of all consult prevent patient travel<br />Each year, 1 to 2 cases caused travel <br />
    92. 92. 63<br />Improving Processes<br />
    93. 93. Ear tube follow up studyThe Value Proposition<br />64<br />254 sets of tubes placed at ANMC in 2000<br />1,000 follow up appointments needed in 12 month period<br />Many of these patients from remote areas<br />
    94. 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.<br />Blinded Study<br />
    95. 95. High level of agreement<br />Correlation between in person exam and telemedicine exam good to excellent<br />Telemedicine can be used to do routine ear tube follow up<br />Make available several hundred appointments per year<br />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.<br /> <br />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.<br />
    96. 96. 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 />
    97. 97. Gaining Efficiencies<br />68<br />Median Time Spent by a Consultant Responding to a Case<br />
    98. 98. 69<br />Referral Management<br />Or why I hate faxes<br />
    99. 99. Large Organization A<br />Large Organization B<br />Small Organization C<br />Small Organization D<br />Alaska Native Medical Center (ANMC)<br />70<br />
    100. 100. All clinics fit somewhere into this pattern with their process<br />Case Manager<br />Physician<br />Faxed <br />Referral<br />or<br />Mid-Level <br />Provider<br />Case Manager <br />Asst.<br />71<br />
    101. 101. Poor quality<br />No record of transmission, receipt, activity<br />Uneditable<br />Get lost, mixed up, resorted<br />Cannot enforce and rules (e.g. field level)<br />Wrong numbers!<br />Why I hate faxes …<br />72<br />Faxed information comes in “batches” and may be incomplete.<br />Each Department has different “forms” and information needs.<br />Manual intervention and phone calls are the rule of the day.<br />
    102. 102. Large Organization A<br />Large Organization B<br />Small Organization C<br />Small Organization D<br />Alaska Native Medical Center (ANMC)<br />73<br />
    103. 103. <ul><li>Forms Designer (used by Clinicians!)
    104. 104. Rich form element types
    105. 105. Integrated database fields
    106. 106. Community driven template library
    107. 107. Supports clinical pathways
    108. 108. Full support for multiuser entry and versioning</li></ul>WHAT IS HOT<br />FORMS<br />
    109. 109. Regional processes need to be designed & tested<br />ANMC Departmental processes need to be designed & tested<br />Regional  ANMC communication needs to be tested &validated<br />Alaska Tribal Health System<br />ANMC<br />Department 1<br />Regional Hospital 1<br />Department 2<br />Regional Hospital 2<br />Department 3<br />Regional Hospital 3<br />Department 4<br />Regional Hospital 4<br />Department N<br />Regional Hospital N<br />Complexity<br />N2 Connections<br />2*N Unique Processes<br />
    110. 110. Large Organization A<br />Large Organization B<br />Step 2<br />Step 3<br />Small Organization C<br />Step 3<br />Small Organization D<br />Step 1<br />Alaska Native Medical Center (ANMC)<br />Step 3<br />76<br />
    111. 111. ANMC “Internal Use” Cases<br />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.<br />
    112. 112. AFHCAN Benefits<br />Route information to the right location<br />Halt the process if information is missing<br />Keep cost and burden of information verification at the front desk level<br />Notify other users<br />… of an AFHCAN case at any point in the referral path<br />See the status of a case<br />Who has it and where is it?<br />Key Process Indicators<br />Workload, turnaround time, creation time, delays in process, etc<br />
    113. 113. 79<br />Lessons Learned<br /><ul><li>Response rate depends on “completeness” of information.
    114. 114. Unstructured data creates miscommunication and creates a reliance on “know how”.</li></li></ul><li>80<br />Improving Relationships<br />
    115. 115. 81<br />36,383 Responses<br />
    116. 116. 82<br />How satisfied were you with the use of the telemedicine technology?<br />Willing to have a telemedicine exam for follow-up?<br />Overall Satisfaction With This Visit<br />How well did the telemedicine technology help you understand your problem?<br />
    117. 117. “I was able to see the problem - then the repaired normal condition … and discussed my problem - very informative!”<br />“I liked to see with my own eyes the inside of my ear!”<br />
    118. 118. 20% of all specialty consultations are turned around in 60 minutes.<br />50%-60% are turned around in the same day.<br />70%-80% are turned around within 24 hours.<br />84<br />
    119. 119. It’s all about relationships …<br />85<br />Almost 250 more patients are being seen per year, a savings in 80 man-years of waiting time.<br />2.6 cases/month <br />7.9 cases/month <br />
    120. 120. 86<br />For this case, rate the following statement:<br />Telemedicine makes my JOB MORE FUN. (n=4,787)<br />
    121. 121. 87<br />Hiring Providers<br />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 />
    122. 122. 88<br />Why you need a “System”<br />
    123. 123. What price telemedicine?(Another word about incentives)<br />
    124. 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.<br />
    125. 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. <br />
    126. 126. S&F telemedicine reimburses less than in person encounters<br />Provider would need to “make up the difference” in increased volume and productivity<br />Reimbursement model undervalues system benefits from S&F telemedicine<br /><ul><li>Cost savings (travel, loss of time from work)
    127. 127. Improved access for care
    128. 128. Addressing disparity in care
    129. 129. Clinical outcomes (?)</li></ul>Summary Points - Under Current Reimbursement System<br />
    130. 130. 93<br />Product Development<br />A word about software …<br />
    131. 131. 94<br />Program Development<br />It’s not just about training …<br />
    132. 132. 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 />
    133. 133. Evolved from a training focus to a bigger picture view that incorporates program development and education<br />Using education as a driver for systemic change<br />Assisting organizations with clinical workflow design, program evaluation & adoption<br />Fostering relationships between referring healthcare providers and consultants<br />Training  Program Development<br />
    134. 134. 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 />97<br />
    135. 135. Connecting the Enterprise<br />Where does Telehealth fit into the <br />“Health Information Exchange?”<br />
    136. 136. Health Information Exchange (HIE)and the role of telehealth …<br />99<br />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. <br />Health Information Exchange (HIE) The mobilization of healthcare information electronically across organizations within a region, community or hospital system.<br />VtC<br />S&F<br />There<br />Space<br />“Classic” EHR/ EMR<br />Here<br />Time<br />Now<br />Future<br />Soon<br />
    137. 137. WHAT IS HOT<br />CONNECTED HEALTH<br />AFHCAN’s success in the past has been by ourselves<br />AFHCAN server<br />AFHCAN server<br />AFHCAN’s future success will be based on how well our system can work with others<br />[your system]<br />tConsult<br />
    138. 138. 101<br />Nationwide Health Information Network<br />101<br />
    139. 139. IS 01: Electronic Health Record (EHR) Laboratory Results Reporting<br />IS 02: Biosurveillance<br />IS 03: Consumer Empowerment<br />IS 04: Emergency Responder Electronic Health Record (ER-EHR)<br />IS 05: Consumer Empowerment and Access to Clinical Information via Media<br />IS 06: Quality<br />IS 07: Medication Management<br />IS 08: Personalized Healthcare<br />IS 09: Consultations and Transfers of Care<br />IS 10: Immunizations and Response Management<br />IS 11: Public Health Case Reporting<br />IS 12: Patient – Provider Secure Messaging<br />IS 77: Remote Monitoring<br />Nationwide Health Information Network (NHIN)<br />“Network of Networks”<br />being developed to provide a secure, nationwide, interoperable health information infrastructure that will connect providers, consumers, and others involved in supporting health and healthcare<br />Policy<br />HISPC<br />The Health Information Security and Privacy Collaboration<br />Standards<br />HITSP<br />Healthcare Information Technology Standards Panel<br />Certification<br />CCHIT<br />Certification Commission for Healthcare Information Technology <br />
    140. 140. Defined Interfaces<br />Samples:<br />C32 – Summary Document Using HL7 CCD<br />May include administrative (e.g., registration, demographics, insurance, etc.) and clinical (problem list, medication list, allergies, test results, etc) information<br />C48 – Encounter Document<br />AFHCAN will be going live with C32 interfaces to EHRs statewide later in 2010.<br />Supports the process of sending patient encounter data (excluding laboratory and radiology)<br />C74 – Remote Monitoring Observation<br />Medical information collected by remote monitoring management systems from monitoring devices and/or device intermediaries<br />C84 – Consult and History & physical note<br />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<br />103<br />
    141. 141. WHAT IS HOT<br />Enterprise Remote Patient Monitoring (RPM)<br />Features<br /><ul><li> Centralized Call Center for multiple organizations
    142. 142. Proposal to fully integrate with EHR
    143. 143. Seamless updates on patient demographics and provider contact info</li></li></ul><li>2003-2009<br />Blending Specialties<br />Remote Consultation<br />Chronic<br />Disease Mgmt<br />Cardiology<br />Oncology<br />Behavioral Health<br />Psychiatry<br />Store & Forward<br />Live<br />VtC<br />Remote Monitoring<br />
    144. 144. 2010 <br />Technology<br />Blending<br />Remote Consultation<br />Chronic<br />Disease Mgmt<br />Cardiology<br />Oncology<br />Behavioral Health<br />Psychiatry<br />Store & Forward<br />Live<br />VtC<br />Remote Monitoring<br />
    145. 145. 107<br />A Changing Landscape<br />Traditional Devices<br />+ New Connectivity<br />+ New Messaging<br /> = NEW SOLUTIONS<br />
    146. 146. WHAT IS HOT<br />BLENDED<br />VtC<br />+<br />Store-and-Forward<br />+<br />IM<br />
    147. 147. WHAT IS HOT<br />FEATURES<br />Connected Health<br />EMR, PHR, HIE, MPI, PACS, Home Health<br />Standards, NHIN, Meaningful use<br />Real-time blended with S&F<br />Work Flow<br />Forms<br />
    148. 148. 110<br />
    149. 149. 111<br />
    150. 150. 112<br />American Telemedicine Association<br />2011 Mid-Year MeetingSeptember 19-21, 2011Anchorage, AK <br />
    151. 151. Thank You<br />Stewart Ferguson, PhD<br />Alaska Federal Health Care Access Network (AFHCAN)<br />Alaska Native Tribal Health Consortium<br />4000 Ambassador Drive <br />Anchorage, AK 99508<br />(907) 729-2262<br />sferguson@anthc.org<br />John Kokesh, MD<br />Department of Otolaryngology<br />Alaska Native Medical Center<br />4315 Diplomacy Drive<br />Anchorage, AK 99508<br />(907) 729-1416<br />jkokesh@anthc.org<br />AFHCAN, Alaska Native Tribal Health Consortium, Anchorage, AK<br />

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