Telemed HCV HIV Townshend Simsons

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  • Statewide surveillance and vaccination programs, as well as present day clinical care can be a challenge in Alaska.This map here shows to scale, the State of Alaska in comparison to the contiguous United States. The red lines indicate our referral pattern for the Alaska Tribal Health System from village clinic all the way to our central hospital in Anchorage. The green lines depict our road systems in the state.We like to say that if Anchorage was Kansas City, Missouri – we have patients in Duluth Minnesota (Far North), Savannah Georgia (Southeast Atlantic Coast) and Los Angeles, California.A large proportion of our hepatitis B patients reside in southwest Alaska, where there is no road access. Access to these communities varies by season, and includes transportation by small aircraft, snow machine and boat.
  • Starting in the village clinic – these are the farthest satellites in the Alaska Tribal Health System. Village communities can range in population from < 100 to more than 500Medical care in the village is conducted by Community Health Aides – these are local residents who go through a rigorous 3 month didactic in basic medical care and techniques. Many village clinics are also equipped with telemedicine capabilities, by which Health Aides can work and communicate with regional doctors, as well as doctors and specialists in Anchorage during patient examination and treatment.
  • Regional Health Centers are in larger population hubs, populations ranging around 1000 to 20,000 residents.These are larger hospitals with greater capabilities, such as ultrasound, CT, small clinical laboratories, and limited operation.Those from village communities must usually fly by small aircraft to be transported to a regional health centerThe Maniilaq Health Center is a good example of Arctic Construction and Design – Buildings must sit up above ground because of the frozen tundra below, which causes instability during every freeze/thaw of the seasons. The permafrost below the top layer of the tundra also prohibits construction design from driving pilings for a firm foundation into the ground.
  • Anchorage is where the only centralized hospital in the state is located. ANMC is home to most specialized care and surgery services for the Alaska Tribal Health System.Patients from regional clinics most often travel to ANMC by commercial airline, which operate 1 or 2 flights a day from the region to Anchorage. (Weather dependent of course!).Alaska Native Medical Center is the highest trauma unit in the State of Alaska, at a Trauma 2 level. Thus, sometimes the patient must be transported once again, to Seattle, which is approximately 1500 miles away, and transported by commercial airline.
  • Not sure I get the links on side of this slide
  • The store and forward software developed by AFHCAN is used throughout the world (pics here showing that our software is being used by the space station; by providers travelling throughout Africa, using portable kits (both pics right and lower left).
  • There are two kinds of telemedicine, store and forward and Video teleconferencing (VTC). Some specialites are best suited for vtc and others for s&f or both. STORE AND FORWARD and vtc telemedicine are reimbursable in Alaska and Hawaii, unlike the lower 48 where only vtc is billable.
  • This is where it is created (rural clinic)
  • Cases received in rural hub or at ANMC specialty clinics. ENT and Dermatology are the two specialties that utlized telemedicine the most.
  • Provider surveyed report using telemedicine because it provides the best care and increased access to care
  • The goal of telehealth is improved patient care.
  • In 2011 over 30,000 telemedicine cases were created. Primary care (blue) are cases that stay within an organization, typically a case created in a village and sent to a provider in a regional hub. Specialty cases are consultations sent to and completed by a specialist at ANMC
  • When the telemedicine program began, a study was completed by the Audiology program showing a significant decrease in wait time. Pre-telemedicine, 47% of patients had to wait more than 4 months to be seen.Providers still travel to rural villages for field clinics. Specialties using telemedicine can spend less time with follow up visits and have more time for sicker patients.
  • Estimated travel savings. Blue line shows travel savings for primary care (not having to travel from village to regional hub) and specialty care (not having to travel to Anchorage to see specialist at ANMC).
  • Friends set-netting (personal subsistence) at the mouth of the Kasiof river.
  • We started LiverConnect on a wing and a prayer. It is a live telehealth program that we started without any grant funding. Myself and our other liver clinic providers participate in University of Washington’s Hepatitis C Project Echo. However, there were special needs to address in Alaska. We saw the need to discuss broader liver disease topics – not just hepatitis C and the 10:45am start time (11:45 Pacific time) didn’t work for us in Alaska.
  • So our staff consists of:
  • Participation in LiverConnect earns the participant 1 CEU/CME for each hour session attended.
  • So a variety of liver disease cases have been presented.
  • Also, we have a broad range of topics presented on liver disease, related topics and comorbid diseases.
  • Here are some of our distant participants visible on screen.
  • We had to move to a larger conference room as the word got out among local providers.
  • We’re working on expanding the program now. We’ll be adding AdobeConnect as a way to access LiverConnect through the internet. Also, we hope to be able to record future LiverConnect programs for later viewing and potentially CME/CEU credit to participants watching the recordings.
  • Possible diagnoses included: Autoimmune hepatitis, alcohol hepatitis. Case discussed among rural provider, participants and liver clinic specialists. Decision made to bring patient in for biopsy.
  • Currently, we have the presentations loaded onto our website – but there is no audio with those Powerpoint presentations, but you can read them.
  • We feel that LiverConnect is just the tip of the iceberg of ways telemedicine can be used to help improve HIV and hepatitis C patient care.Coord care: example – transplant coordination.
  • If you want to start your own program, these are some of the main questions we asked ourselves…
  • Items to consider:Do you have IT support?If you use a program such as Adobe Connect, do you need multiple licenses?Figure out how you will handle protected health information.Advertising – How? To Whom?Feedback – Complete evaluations after each session. How do you evaluate those who are not using the service?
  • Alaska also has a Telehealth Technology Assessment Center which evaluates telehealth equipment and works closely with telehealth resource centers to provide answers to questions about selecting appropriate technologies for telehealth programs. Website www.telehealthtac.org
  • The Telehealth Technology Assessment Center or TTAC provides an unbiased source of rich information on a wide variety of telehealth technologies. The TTAC serves to raise awareness of technologies, answer questions, compile information from vendors and other sources and perform in-house evaluations on technologies. The TTAC shares the information through local, regional and national channels. The TTAC tailors its service offerings based on collaboration with the 11 regional Telehealth Resource Centers or TRCs across the United States. Services rendered vary from simple phone consultations to highly complex toolkits covering the evaluation and selection of specific technologies. Their published works, recorded webinars and other resources can be found on their website at www.TelehealthTAC.org.
  • AFHCAN = Alaska Federal Health Care Access Network.www.afhcan.org for more information
  • AFHCAN offers a variety of training and educational opportunities. AFHCAN Training Program is accredited by the American Telemedicine AssociationStarting in 2011, the AFHCAN program, in collaboration with the University of Alaska began offering online certification courses in telehealth.www.afhcan.org for more information
  • Thank you. Brenna and I will be happy to take questions, comments about LiverConnect and telemedicine.
  • Telemed HCV HIV Townshend Simsons

    1. 1. Telehealth Use for Hepatitis C and HIV Telemed Experiences from Alaska Brenna Simons,PhD Lisa Townshend, ANP Alaska Native Tribal Health Consortium
    2. 2. Patient Care in Alaska: Many Challenges
    3. 3. From the Village Clinic….
    4. 4. …to the Regional Health Center…
    5. 5. …to the Central Hospital
    6. 6. Nuiqsut to Anchorage Point Hope to Anchorage $1100 $980Savoonga to Anchorage $1000 Chevak to Anchorage $950 Old Harbor to Anchorage $1350
    7. 7. Telehealthcan be usedto bridgegaps inspecialtycare So, what is telehealth? State of Alaska Health and Social Services, Division of Public Health www.hss.state.ak.us/dph/healthplanning/telehealth
    8. 8. 8
    9. 9. Telehealth in Alaska Tribal Health System Cases Created per Year 11 year Operational 35,000 30,000 History 25,000  33,000 cases/yearCases Created 20,000 15,000  125,482 Cases (ATHS) 10,000 5,000 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Installed Customer base includes:  Alaska: 248 sites, 44 organizations 59 operational systems in 2011 1,443 providers in 2011 22,763 patients in 2011  Other states and countries 9
    10. 10. Telehealth Terminology Live-interactive Refers to telemedicine encounters where the patient, primary careprovider with the patient, and the specialist in a different location are on-line at the same time, interacting real-time and not delayed. Store-and-forward In contrast to live-interactive telemedicine encounters, this meansthe health provider where the patient is at stores the data from theencounter in a digital format, and then forwards the data to a specialist. Health Information Exchange The coordination of appropriate electronic records for the healthneeds of the patients and providers. Security is governed by patient andfacility permission levels. State of Alaska Health and Social Services, Division of Public Health www.hss.state.ak.us/dph/healthplanning/telehealth
    11. 11. Store & Forward vs Real-Time Store & Forward Telehealth Real-Time (VtC) • Asynchronous Interaction • Face-to-Face • Documents & Images Remote Interaction consultation • Immediate • Electronic Medical Records Feedback • Patient Education • Radiology • Cardiology • Psychology/ PsychiatryClinicalspecialties for • Dermatology • ENT • Neurologytelemedicine • Pathology • GI • Speech therapy • Oncology • Pulmonary • Physical therapy • Ophthalmology • Rheumatology • Dental 11
    12. 12. Store and Forward Telemedicine  Ear Disease  Audiometer, Tympanometer, Vide o 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 12
    13. 13. 13
    14. 14. Case originated…
    15. 15. …Case received.
    16. 16. Why Do You Use Telemedicine? Best for patient care Helps me communicate with a doctor Saves my organization money Most convenient to the patient Improves patient satisfaction Makes me more efficientGives me confidence in doing the right thing for the patient Increase access to care 0% 10% 20% 30% 40% 50% 60% 70%  Best for patient care  Increased access for care 16
    17. 17. Outcomes
    18. 18. Cases Created per Year (by Role) 35,000 30,000 Cases Created 25,000 20,000 15,000 10,000 5,000 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Primary Care Specialty CareATHS (Alaska Tribal Health System) (1/1/2001 to 12/31/2011) 18
    19. 19. Telehealth Impact on Extended Waiting Times (> 4 months) 50% 47% Percent Appointment Availability With 5 45% 40% Month or Longer Wait Time 35% 30% 25% 20% 15% 10% 8% 5% 3% 0% Pre-Telemed With With 1991-2001 Telemed Telemed (n=1216) 2002-2004 2005-2007 (n=276) (n=210) Data courtesy of Phil Hofstetter 19
    20. 20. Annual Travel Savings (by Case Role)$7,000,000$6,000,000$5,000,000$4,000,000$3,000,000$2,000,000$1,000,000 $0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Primary Care Specialty Care 20
    21. 21. How We Use Telehealth for Hepatitis C/HIV
    22. 22. GoalsProvide consultationto rural providers inAlaskaPromote educationabout liver disease CEUs/CMEs Case study formatRelaxed setting forasking questions
    23. 23. ANTHC Liver  Early LiverConnect MeetingDisease &Hepatitis Staff2 Physician LiverSpecialists1 Nurse Practitioner1 Microbiologist5 Nurses1 InformationTechnologist3 Administrative/Support Staff
    24. 24. How does LiverConnect Work? Case Created byRural Provider LiverConnect LiverConnect Staff Videoconference Notified Rural Provider LiverConnect Copy of Of Case Presents Case & Treatment Relevant Recommendations Powerpoint Liver Clinic Providers Notes, Made by ANTHC Slides Discuss Case. Labs/Tests Liver Disease Providers Scanned to Created plus via AFHCAN AFHCAN About Case Liver Disease or Related Topic Presentation Follow UpPatient Form Completed for FutureLiverConnect
    25. 25. Case Types Presented at LiverConnect Elevated LFTs Autoimmune Hepatitis Hepatitis C Treatment Hepatitis B Treatment Hepatocellular Carcinoma Liver Transplant Alcohol Hepatitis Hepatitis C and HIV Coinfection Patient with Liver Disease in Jail
    26. 26. Didactic Presentations Given at LiverConnectLiver Disease Topics Related Topics  Elevated LFTs  HIV Updates  Hepatitis B  Elevated LFTs and HIV  Hepatitis C  Depression  Autoimmune Hepatitis  Rheumatologic  NAFLD Manifestations of HCV  Alcohol Hepatitis  Motivating Patients with  Statins and Liver Disease SA and Liver Disease  Liver Transplantation  Adverse Childhood Experiences Study  Hepatocellular Carcinoma  Suicide Prevention
    27. 27. Distance Participants
    28. 28. Local Participants at LiverConnect
    29. 29. Using AdobeConnect for Videoconferencing
    30. 30. Recent LiverConnect Case Study 34 y.o. Alaska Native female Presents with nausea/vomiting Icterus Afebrile No abdominal pain
    31. 31. Case YK-8 LabsInitial Labs 10/1/11 Initial Labs 10/1/11ALT 1166 ANA NegativeAST 896 Actin Antibody 189Alkaline phos 226 IgG 2320Total bilirubin 7.43 IgM 222Hemoglobin 12.2 Hepatitis A IgM NegativeHematocrit 37.7 Hepatitis A Ab Total Reactive/PositiveWBCs 6.5 Hepatitis B Core IgM NegativePlatelets 347 Hepatitis B Surface Ag NegativeProthrombin Time 12.9/Inr <1 CMV NegativePTT 36.1 Monospot Negative
    32. 32. Case YK-8 Provider Questions What’s the differential diagnosis? What other labs/tests are needed? Does patient need liver biopsy?
    33. 33. Case YK-8 Diagnosis - AIH ANA negative, Actin antibody positive, IgG elevated Liver Biopsy: AIH with marked activity and early bridging fibrosis. Initial Treatment:  Methylprednisolone 32mg and  Azathioprine 25mg.
    34. 34. Case YK-8 Follow Up Feb 2012 Current labs: ALT: 36, AST: 32, WBCs: 9.5, ANC: 7.5, Hemoglobin: 10.5, Platelet Count: 425 Vitamin D 25OH Total: 10 DEXA Scan: Osteopenia AIH Medications: Azathioprine 75mg p.o. daily and Methylprednisolone 7mg p.o. daily
    35. 35. Case YK-8 Follow Up Provider Questions What should I be concerned about? What tests should I order on her and when? How long should she stay on azathioprine and methylprednisolone?
    36. 36. Contact InformationPast LiverConnect Presentations Viewable at ANTHCLiver Disease & Hepatitis website: http://www.anthctoday.org/community/hep/liverconnect.html
    37. 37. How Telehealth Can Be Used in HCV and HIV Care  Training Providers, Nurses, Health Aides  Disease Management Updates  Treatment Updates  Comorbid Diseases  Case Management  Consultation for Difficult Cases  Interactions Among Teams for Coordinated Care  Direct Patient Interactions  Check-in  Reiterate education given  Value of seeing patient face-to-face
    38. 38. Telehealth In Your Community • Getting Started • What do you want to accomplish? • What do you need to do this? • What works best? • Technology options
    39. 39. Establishing a Local Telehealth Program Technology Requirements Legal Requirements Handling Protected Health Information Advertisement Feedback Mechanism
    40. 40. 40
    41. 41. Creating better-informed consumers oftelehealth technology. Kirt J Beck Follow Us TTAC Director kjbeck@TelehealthTAC.org Main: 907.729.4703TelehealthTAC www.telehealthtac.org 41
    42. 42. AFHCAN Training Options AFHCAN offers a variety of training and educational opportunities  Train the Trainer  Super User 3-day  Telehealth Technical Support  Videoconferencing user training E-learning options:  Videoconferencing (VTC)  Webinar  AFHCAN computer-based training (CBT)
    43. 43. University of Alaska College Courses• AFHCAN & University of Alaska offer three college courses in telehealth – Course 1- Telehealth Fundamentals – Course 2 – Beyond the Basics of Telehealth – Course 3 – Telehealth Program Management• Completion of Courses 1&2 -certification as Telehealth Coordinator• Completion of all 3 courses -certification as Telehealth Program Manager• More information at www.afhcan.org
    44. 44. Thank You!

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