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  • The Army PACS world is carved up into various vendor PACS and Teleradiology Products as depicted in the slide. Our Global Teleradiology Program is implemented on top of PACS to provide secure transmission and access to Teleradiology exams anywhere needed. We are using the Medweb product for this, and the Navy and Air Force have adopted this product as well for their new telerad sites. TATRC is working to get other telemedicine applications ported over to this same platform, e.g. TeleDerm, Path, Ocular, and other; - preserves the principle of “conservation of boxes” and simplifies operation and support
  • Remote interpretation of echo cardiology exams began in November 1997 between Fort Sill and BAMC using a VHS video tape mailed from Sill to the cardiologists at BAMC for interpretation and was expanded to Fort Polk in Mar 1998. In 2002, the cardiology system at BAMC was upgraded to a digital system allowing the elimination of video tapes and a transition to exam movement through the network with further expansion of the program to Fort Hood, Fort Carson and Fort Leonard Wood. For echocardiology, a site must have an echocardiograph and a sonographer and access to a cardiologist. In Tele-echocardiology, the access to the cardiologist is provided by digitally moving the exam to BAMC who has a contract cardiologist interpret the exam at a cost of $65 per exam. This compares to a cost of $600 to $1000 if that patient is referred to a network cardiologist. In calendar year 2002, BAMC interpreted 997 exams at a cost savings of between 500,000 and 1,000,000 dollars. BAMC’s Health Plan Management is working a business case analysis to fund the contract exam interpretation cost for FY 04.
  • The military has lost 50% of their dermatology physicians in the last ten years and the forecast is we will continue to lose dermatologists. Teledermatology can be used to overcome this loss. The patient benefits the most from improved access and higher level of care. In many of our remote MTFs the waiting time to access a network dermatologist approaches three months. The primary care providers are empowered with dermatological knowledge and are able to provide a better quality of care for future patients with dermatology problems through participation in T-Derm. The AMEDD benefits by being able to more efficiently utilize our limited dermatology resources and reduce overall healthcare costs. Teledermatology is clinically effective which, is backed by published peer reviewed studies. Close to 90% of all dermatological conditions can be managed via teledermatology. Today, there is no financial incentive for an MTF to spend their limited resources to recapture dermatology workload currently being sent to the network. However, when TNEX goes into effect, MTF’s will have an incentive to recapture using teledermatology. Our program is focused on revising the business process to maximize the utilization of teledermatology by having a consult manager review consult requests and capture referrals for dermatology prior to them being appointed to see dermatologist or sent to the network. At our test site, Fort Hood, we provided a dedicated resource to the MTF to take the images and manage the program. This enabled us to change the business process to allow teledermatology to be integrated into the existing consult flow with outstanding results as shown in the graph in the lower right corner. Since Teledermatology began at Hood in Feb 02, the number of purchased care claims decreased by 79% when you compare Feb 02 to Sep 02. This downward trend has continued through the first five months of FY03. In short, the new business process minimally changes the normal workflow of the primary care provider. We have submitted a venture capital business case analysis to expand the Fort Hood model to other MTFs in the Region (FY 04 cost is $769K). Teledermatology began in Feb 2002; with a focus of supporting sites without a dermatologist or those not meeting access standards for dermatology care. All images are captured at the site and sent to the telederm server at GPRMC. The dermatologist responsible for interpreting the images logs on to the web server and answers the consult request (the 3 sites listed rotate responsibility for interpretation). There is a great potential for recapturing referrals from the network.  
  • EWRAS: CONOPS developed by the HIPAA R&A WIPT M-EWRAS: CONOPS developed by the EWRAP IPT EWRAM: The name adopted by CITPO for the implementation of the M-EWRAS CONOPS

Transcript

  • 1. U.S. A RMY M EDICAL R ESEARCH & M ATERIEL C OMMAND MG Eric B. Schoomaker, Commanding Deputy for Advanced Technologies COL Karl Friedl, MC, USA Director, Telemedicine & Advanced Technology Research Center (TATRC) LTC (Dr) Hon Pak, MC, USA Chief, Advanced Information Technology Group M EDICAL M ATERIEL D EVELOPER Protect the Warrior… Sustain the Force!
  • 2. Disclosure
    • Chairman, Standards and Guidelines of ATA
    • Deputy Chair, Telemedicine Taskforce, American Academy of Dermatology
    • President-elect and Board of Directors, American Telemedicine Association (ATA)
    • Teledermatology Consultant, Army Surgeon General
    • Chief, Advanced Information Technology Group, TATRC
  • 3. MISSION
    • Apply physiological and medical knowledge, advanced diagnostics, simulations, and effector systems integrated with information and telecommunications for the purposes of enhancing operational and medical decision-making , improving medical training , and delivering medical treatment across all barriers .
    • The program scope is to identify, explore , and demonstrate key technologies and biomedical principles required to overcome technology barriers that are both medically and militarily unique.
    Department of Defense, Joint Warfighting Science and Technology Plan, Chapter IX, Joint Readiness and Logistics, 1999
  • 4. TATRC Programs
    • Congressional Special Interest RDT&E (70+ Programs)
    • Office of the Surgeon General AMEDD Advanced Medical Technology Initiative (AAMTI) (70+ Projects)
    • SBIR/STTR Small Business Innovative Research/Small Business Technology Transfer (50+ Projects)
    • Telemedicine
    • DARPA Programs (25+ Projects)
  • 5. “ Integrating Telehealth Technologies Into DoD EHR Network”
  • 6. Agenda
    • Current telemedicine investments
    • Arrival of AHLTA- our EHR
    • The “gap” of EHR
    • Convergence of EHR and telemedicine
  • 7. NAVY MEDCENS SERMC DDEAMC GPRMC BAMC PRMC TAMC Air Force MEDCENS WRMC MAMC 18 th MEDCOM 121 st General Hospital NARMC WAMC WRAMC Iraq Kuwait Afghanistan Balad ( Army & Air Force ) Baghdad Mosul Arifjan TMC ( Army & Navy ) Beuhring Ali Al Salem ( Air Force ) Theater Teleradiology Business Process A Theater Approach to Soldier Health Care: Teleradiology ERMC LRMC Germany Bahrain ( Navy ) Cropper Bucca Talil Tikrit Baghram Kandahar Salerno Kabul (Projected) Exams Work over flow / Medevac Radiologist LEGEND
  • 8. Army Telepathology Program
    • 13 new virtual slide scanners - $800K
    • Infrastructure upgrade for AFIP Telemed - $250K
  • 9. Western Ft. Irwin Ft. Lewis (MAMC) Ft. Wainwright Pacific Tripler (TAMC) 121st General Hospital GE PACS Ft. Monmouth Ft. Sill Ft. Drum West Point Ft. Carson Ft. Huachuca Ft. Hood Ft. Sam Houston (BAMC) Ft. Polk Ft. Knox WRAMC Ft. Leonard Wood Ft. Riley Ft. Leavenworth Ft. Eustis Ft. Lee Ft. Meade Ft. Belvoir WBAMC North Atlantic Great Plains Ft. Bragg Redstone Arsenal Landstuhl Heidelberg Wuerzberg Siemens PACS Europ e Ft. Jackson Ft. Campbell Ft. Stewart Ft. Gordon (DDEAMC) Ft. Rucker Ft. Benning Ft. McClellan Digital Radiology– Where are we today? Agfa PACS IBM PACS Southeast Ft Buchanan, PR JTF Bravo
  • 10. Tele-Health Initiatives Tele-Echocardiology
    • Availability of echo depends on access to sonographer, equipment and cardiologist
    • Digital echo and telemedicine technology bridge the gap to specialty diagnostic imaging
    • All echos are read at BAMC
    • Cost savings for MEDDAC
      • Civilian cardiologist office echo plus interpretation ~ $600 to $1000
      • Our contractor: read cost is $73
    • $434.4K funded as Venture Capital (ROI) on FY06 resource summary; transitions to base in FY07 ($452.2K)
    Jan 2002 – Jun 2006 – 10,746 exams Purchased care would have cost $3,544,454
  • 11. AKO.Consult Program Summary
      • [email_address]
        • Managed by the Institute for Surgical Research, Ft Sam Houston
      • [email_address]
        • Managed by BAMC Cardiology
      • [email_address]
        • 4 Call Teams: BAMC, Walter Reed, Western, and Atlantic
      • [email_address]
        • On-call ophthalmologists based in Germany and Eastern US
      • [email_address] (Infectous Diseases)
        • 3 Call Teams: BAMC, Walter Reed, and Western
      • [email_address]
        • Managed by various Army, Navy, and Air Force call teams
      • [email_address] (Pediatrics Intensive Care)
        • Walter Reed based with call teams from Hawaii to Germany
      • [email_address]
        • Preventive Medicine and Occupational Medicine … managed by CHPPM
      • [email_address]
        • BAMC based with participation by all DoD toxicologists
      • [email_address]
        • Managed by TAMC with participation from many MTFs
  • 12. AKO Teleconsultation Summary
    • Program Summary
      • 10+ specialties with contact groups: [email_address]
      • 1,886 teleconsultations (April 2004 to July 2006 – 29 months)
      • 47 known evacuations prevented
        • 3 evacuations prevented in August
      • 42 known evacuations facilitated following consultant’s recommendation
        • 5 evacuations facilitated in August
      • 648 different referring health care professionals
      • 250 teleconsultations on non - US patients
      • Average Reply Time 5 hr 9 min
  • 13. Tele-Dermatology
    • 17,805 consultations since inception of program
    • 18 reporting facilities
      • 188 Army consults or 62% of total
      • 92 Air Force consults or 30% of total
      • 23 Navy consults or 7% of total
    • $825.4K funded as clinical deficiency on FY06 resource summary
    Feb 02 – May 05 – 12,428 consults answered Army Site Air Force Site Navy Site GITMO
  • 14. NARMC Tele-Neurosurgery Optimize Specialty Care
    • PA screening optimizes neurosurgeon
    • Conservative care improves clinical outcomes
    • Recapture related RAD/PT/surgery fees/lab
    • PA/Nurse Manager provide
    • case management
    •  
  • 15. Tele-Behavioral Health (WRAMC) Clinical Business Process
    • Referral Management and Promotion
    • MTF managed care staff and Health Net support referrals
    • Market initiative to beneficiaries at each referring site
    • Establish referral process/rules to exceed access standards
    • Review civilian hospital behavioral health admissions daily
    • Psychiatrist Scheduling
    • New patients/follow-up/walk-ins/ER patients/MEBs
    • Therapist screening (triage) to prioritize patients
    • Immediate aftercare for early release of inpatients
    • Patient Follow-Up Care
    • Psychiatrist follow-up VTC visits are based on treatment plan
    • Psychiatric NP provides VTC med mgmt clinic for stable patients
    • Therapists take over care for long-term stable patients
  • 16. DoD Telemedicine Summary
    • Multiple Disparate Systems
    • High and Low Bandwidth telemedicine systems
    • Live Interactive and Store and Forward System
    • Lack of centralized portal for both military and network providers
    • Shortage/maldistribution of specialists
  • 17. Scope of MHS Operations
    • Average Weekly Statistics, 2005
    • Direct Care Visits:  590,222
    • Direct Care Admissions: 5,486
    • Direct Care Dental Visits: 99,000
    • Direct Care Births: 1,070
    • Direct Care and Purchased Care Visits: 1,885,555
    • Direct Care and Purchased Care Admissions: 20,667
    • Direct Care and Purchased Care Dental Visits: 104,000
    • Direct Care and Purchased Care Births: 2,228
  • 18. AHLTA Deployment Statistics
    • As of 25 Aug 2006:
      • Full use by 130 out of 138 MTFs
      • 56,618 out of 63,000 users trained
      • 27.3 million visits captured since Jan 2004
      • Contains records for 8.4 million beneficiaries
      • Documents 96,800 patient visits per day electronically (per 21-25 Aug 2006 survey)
      • Contains 544,000 theater patient encounters
      • 32,000 encounters sent from Theater to Garrison in July 2006
  • 19. Telemedicine Gap of AHLTA
    • The “gap” of EHR
      • Autoregistration of virtual patients
      • Workflow: Ability to route consults outside network or facility
      • Ability to order consults with images
      • Workload capture/split
        • Professional v. Acquisition
  • 20. Integration effort
    • Telehealth Portal
    • Others
      • Tricare On Line
      • DFI
      • Document Engine (workflow)
      • EWRAM
  • 21. TRICARE ON-LINE (TOL)
    • Portal for MHS Clinicians and Beneficiaries
    • Single Sign On (SSO) to MHS Applications under development
    • Linked to DEERs for eligibility checking
    • Primary Means To Support Consumer Empowerment
      • Can make appointments
      • Pharmacy refill under development
      • Health Content for Patient Reference
      • Health Assessments
      • Deployment related links
      • Non-availability statements
      • Personal Health Manager (journal and tracker) and Personal Health Record (demographics, allergies, medication and appointment profiles) under development
      • Home Page being re-designed
  • 22. TRICARE Online (TOL) Schema Beneficiaries Providers/ Staff External Support Contractors Single Sign-On Defense Medical Human Resources System – internet (DMHRSi) Patient Safety Reporting (PSR) CHCS Defense Enrollment and Eligibility Reporting System (DEERS) Current TOL Applications and Services Single Sign on to MHS Systems (in progress) 104 Military Treatment Facilities Health Content Deployment Related Links Secure Provider Access CHCS (SPAC) Portal to Portal Single Sign-On Services to TOL Others Health Assessment Centralized Credentials & Quality Assurance System (CCQAS) Deployment Related Medical Records Online (DRMROL) AHLTA/Clinical Data Repository Non Availability Statements (NAS) Composite Health Care System - CHCS Service Portals Appointing External Systems Military Health System (MHS) Portal SSO
  • 23. TRICARE Online Current Capabilities
    • Online appointing
      • Automatically checks eligibility for care
    • Information on MHS Services and Benefits
    • 18 million pages of Health Content
    • Online drug interaction checking
    • Non-Availability Statement (NAS) processing
    • Secure Access to Composite Health Care System (CHCS)
    • Access to Deployment Related Records Online (DRMROL)
  • 24. Document,Files,Imaging (DFI)
    • Provides ability to capture, identify, and present DFI to the clinical user within the context of clinical workflow.
    • Current MHS environment presents numerous instances in which in hard copy and digital clinical encounter documentation originating from outside sources needs to be incorporated into AHLTA
    • This project is essential for ensuring that the healthcare professional has a complete and comprehensive record for use while delivering quality patient care.
  • 25. Document, Files, Imaging (DFI), continued AHLTA Client DFI module
    • DFI List
    • DFI View
    Scan/Import Tool DFI Management Sub-System DFI Repository
    • DFI Retrieval Service
    • DFI Import Service
    View Purchased Care Data Electronic Document [Future] MTF PACS (Agfa Web) Broker for person Identifier (DEERS PIDS fetch) Indicates Scanning/Import Tool ECP 915 Indicates Digital Imaging ECP 920 Indicates View Purchased Care Data ECP 919 DFI Registry
    • DFI Registry Query Service
    • DFI Registration Service
    • Scan/Import
    Paper Document
  • 26. Document Engine/AHLTA Integration System Architecture Legends: Available To Be Implemented Oracle HTTP Server Document Engine Server OC4J (J2EE) Container DE Application DE Web Services Transcription System LCS Server JDBC Transcribed docs HL7 Messages: ADT, SCH … HL7 Messages: ADT, SCH … Document Capture Driver AHLTA Client WS Document Capture Applet Integration B2B HL7 Engine System Print Services Port 443 Port 443 Listener Port (e.g. 1521) LGSFEP #2 Server Generic Interface Port 443 Pulmonary Function System Medical Records Printers CHCS AHLTA DE Web Services AHLTA DE Module ICD Core Module XML Proxy Listener Port (e.g. 1521) CWSFEP ICD Enc. Mapper CDR Enc. Mapper Encounter Mapper DE HL7 DE CDR
  • 27. Document Engine (DE)
    • DE module provides a universal, standard interface for incorporating clinical documents into patient records. Comprehensive information capture is provided from the following:
      • Clinical text Health Level Seven (HL7) messages,
      • Print jobs from other Windows applications, and
      • Print jobs via serial port data from legacy hardware devices.
    • Project to integrate GOTS Document Engine (DE) into AHLTA to provide interface to import documents from external vendors, other print-capable Windows software, and legacy hardware.
    • Allows users to manage unsigned documents through a delegation, review, and signing workflow.
  • 28. Enterprise Wide Referral and Authorization Module (EWRAM)
    • Background:
      • Per HIPAA Law, covered Entities are Required to use Standard Transactions (X12 278) for all Electronic Referral & Authorization Requests
      • If MHS Sends / Receives Electronic Referral Request, (X12 278) Required
      • Faxing Not Considered Electronic
      • Long History of Development of CONOPS through Flag-led WIPT and negotiations with MCSCs on what is required
  • 29. Enterprise Wide Referral and Authorization Module (EWRAM)
    • HIPAA R&A WIPT: HIPAA OIPT Referral & Authorization (R&A) WIPT Created to Address Direct Care Business Process & HIPAA R&A Transactions Between MTF and MCSC
    • EWRAS: Enterprise Wide Referral and Authorization System
    • NAS: Non Availability Statements : Permits TRICARE Non-enrolled Beneficiaries to Receive Inpatient Care in the Civilian Market (NDAA 2002 – Mental Health Care only); Europe Uses NAS System For Referrals
    • EWRM: Enterprise Wide Referral Management IPT
    • EWRAP: Enterprise Wide Referral and Authorization Process IPT
    • M-EWRAS: Modified-EWRAS as a CHCS II Module
    • EWRAM: Enterprise Wide Referral and Authorization Module
  • 30. EWRAS Interfaces MCSC TOL CENTRAL SERVER (at DISA) REFERRING PROVIDER ENTERS REFERRAL INTO EWRAS MTF HUB DEERS CHCS Ref. Approved to Direct Care Appointment 271 270 HL7 278 Civ Net INTERFACE ENGINE Referral Request, Status Updates, & Results 271 270 INTERFACE ENGINE MCP Request, Appointment Specialty Provider or Transcriptionist Enters & Verifies result into EWRAS
    • High Reliability & Availability
    • Local Redundancy
  • 31. Telehealth Convergence
    • Telehealth as portal into AHLTA
    • Single Point of Entry
      • Network providers
      • MHS providers
        • Deployed Environment
        • Fixed Facilities
        • From Specialist’s Home or remote location
    • Seamless workflow with AHLTA
      • Single view/ desktop
      • Leveraging existing and ongoing functionalities
      • Process over existing infrastructure
  • 32. Telehealth Portal
    • Outsourcing Specialists
      • Most of our patients are seen by our network providers (Tricare)
      • Leveraging telehealth to optimize delivery of healthcare
      • Contract Process (Tricare Contract)
        • Ensure that Telehealth is used especially when specialty access is not available by traditional means
    • Second Opinion
      • CDC
      • Subspecialty Care
        • Pediatric genetics
  • 33. Summary
    • Telehealth Portal from Walter Reed
      • Require backend integration with Tricare On Line
    • Gap Analysis and Convergence
      • Tricare On Line
      • Document, File, Images
      • Document Engine
      • EWRAM
  • 34. Questions
    • Hon Pak
    • [email_address]
    • 301-619-7923