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  • AFHCAN Project Stewart Ferguson, Ph.D Associate Project Director Director of Technology AFHCAN Project Office Alaska Native Tribal Health Consortium 907-729-2260 www.afhcan.org
  • AFHCAN Sites
  • AFHCAN Partners
    • IHS - 194 sites - 97,000 beneficiaries
    • VA - 1 site - 65,000 beneficiaries
    • US Army, US Air Force - 9 sites - 47,000 military and dependents
    • USCG - 4 sites - 3,000 beneficiaries
    • Alaska PHN - 26 sites
  • “Remoteness” by Access
  • Cost of Travel
  • “Types of Sites” by Staffing
  • NLM - Maniilaq Data
    • 11 Village clinics
    • Begin: 1/26/1999
    • Gather: 1/15/2001
    • 2863 Cases
    • 8594 Images
      • 3393 Video otoscope (40%)
      • 5061 Digital camera (60%)
  • Lessons Learned from NLM...
    • Software too difficult
      • “ If you don’t use it regularly, then you will forget how to use it”
    • Radio Medical Traffic
      • “ 20 cases in 30 minutes”
  • Radio Medical Traffic
    • Daily telephone calls
    • 90 seconds / consult
    • Telemedicine facilitates this process
  • What is Telemedicine? “ Telemedicine involves the transfer of health data over a telecommunications system.” Ask-a-Doc Home Health Store & Forward RMT Radio/Phone/Fax Remote RPMS VideoConference Remote Surgery Single Provider Multiple Providers
  • Workload Distribution
  • What are your key organizational goals for telehealth applications? Please rank in order of importance to your organization:
    • Access to care
    • Patient Satisfaction
    • Quality of Care
    • Information Transfer
    • Costs/Economics
    • Continuity of Care
    • Other
  •  
  • AFHCAN Referrals
  •  
  • AFHCANet
    • Alaska Native Medical Center (1)
    • Veterans Administration Medical Center (1)
    • Maniilaq Health Corporation (13)
    • SouthEast Regional Health Consortium (12)
    • Kodiak Area Native Association (6)
    • Eastern Aleutian Tribes (8)
    • Norton Sound Health Corporation (15)
    • Public Health Nursing (?)
    • Yukon Kuskokwim Health Corporation (47)
    • Bristol Bay Area Health Corporation (30)
    • Dialup connectivity (up to 23)
    • Commissioned - EAFB (1)
  •  
  •  
  • VoIP - Anchorage Dial Tone
    • Provide 24 dial tones in Anchorage
    • Integrate T1 into PBX at sites:
      • SEARHC, KANA, NSHC, MHC
    • Least cost routing
    • Monitor traffic and cost savings:
      • NSHC spends >$2000/mo
      • T1 cost ~$900/mo
      • 24 dial tones ~$25/mo each
  • CLINIC NETWORK AFHCAN SYSTEM CART Otoscope ECG Scanner Touchscreen CPU UPS LAN Access Point Hub PRINTER Print Server Printer SERVER AFHCAN Cold Fusion SQL Server Web Server O/S CPU BASIC COMPUTER Monitor CPU WAN Router AFHCANet
  • AFHCANet POTS/WAN Facility “C” CHA #3 CHA #4 Router C Facility “B” CHA #1 CHA #2 Server B Facility “A” M.D. #1 M.D. #2 Server A HTTPS/XML
    • CLIENT
    • Operating System
      • Win95/98/NT/2000
      • (Unix/XWindows)
    • Browser
      • IE v4.01/v5
    • Acquisition Hardware
    • Frame Grabber
    • Biometrics
    • SERVER
    • Operating System
      • WinNT/2000
      • (Unix/Linux)
    • Web Server
      • IIS, Apache
    • Cold Fusion
    • Database Server
      • SQL, Access
    • Archive hardware
  • Sustainability
    • Organization owns equipment
    • Training provided on:
      • Assembly, testing, burnin
      • Software installation / management
      • Clinical design
      • Clinical usage
  • 1) Keep it Simple.
    • Minimal computer skills
      • Touchscreens
    • High turnover rates (re-training)
      • Few choices per screen, color coded
    • Language barriers
      • Very selective word choice
    • Disparate educational levels
      • Reduce complexity to few components
  • 2) Make it Sustainable and Supportable.
    • Easily maintained
      • Open source design (.CFM)
      • State Machine
    • Centralize “Point of update” or “Point of Code”
      • Web solution - NO custom clients
      • remote upgrades
    • Minimize initial and recurring costs
      • No ongoing licenses
  • So many organizations … so many software issues!
    • >1000 Workstations
    • >100 Servers
    • WinNT, Win2000, Unix, Linux
    • IE3, IE4, IE5, Netscape, Xwindows
    • POTS to T1 connectivity
    • Different patient encounter forms
    • RPMS / CHCS / VISTA / Meditech
    • Funds disappear in 2 more years
  • A properly designed system can improve the quality of health care delivery without saving or sending a single byte.
  • Satellites
    • Add 0.6 seconds to roundtrip delay
    • Cause web pages to load in 5 - 40 seconds
    • Solutions:
      • Remove need for frame sets
      • Caching locally
      • TCP/IP registry tweaks
      • Different IP stack
      • IE (http) registry tweaks
      • 3rd party software (e.g. Flash Networks) - mostly proxy/spoofing techniques
      • 3rd party hardware
  •  
  • Effect of Proxy / SSL
  • Alaska Federal Health Data Sharing Planned Project Relationships What the AFHCAN software is not ... VISTA CHCS T2P2 ? GCPR MFI Telerad AFHCAN PACS Integrator HIS Telehealth CPRS ANMC 1/02-6/03, field start 9/03 CPRS Phase I deploy 7/00 RPMS Alpha 3/01-7/01 Beta 7/01-12/01 Phase III 2/02 RAHALL 4/00 version4 ANMC billing 6/00-10/00 Adding lab & meds Adding 10 yr data existing planned possible Going to CHCSII NPIRS/ ORYX
  • AFHCAN Evaluation
    • Usage - all
    • Evaluation questions - all
    • Voice over IP - SEARHC, KANA, NSHC, MHC
    • PE Tube Followup - MHC
    • Video Conferencing - SEARHC
    • Ear Disease - YKHC
    • FAS Clinic - SCF
  • FAS Clinic (SCF)
    • Team Approach - based on University of Washington’s nationally recognized model
      • Pediatrician
      • Pediatric Psychologist
      • Physical Therapist
      • Speech and Language Therapist
      • Social Worker
      • Parent Navigator / Advocate
      • Clerk
      • Coordinator
  • FAS Clinic (SCF)
    • Purpose - Develop diagnosis and treatment plan for FAS
    • Method - Interviews with parent and child
    • Technology
      • VtC (digital one way mirror)
      • Nikon 990 (dysmorphology)
    • Future - travel team, travel equipment
  • PE Tubes
  • PE Tube Followup
    • National standard - 4 month followups
    • Reality - 8 month or longer
    • Expect up to 90% of followups can be accomplished with reverse telemedicine
    • Is an image as good as an “on site” visit?
      • Two independent “on site, in person” assessments. Take images
      • 6 and 12 weeks later, conduct assessments from images alone.
      • Compare inter-provider variability, “on site” versus “image” assessment and treatment plans
  • Develop standards to … ENHANCE the interoperability of disparate telehealth systems and applications. IMPROVE the sustainability and usability of such systems in future years. Provide a mechanism for meeting current and projected FUTURE needs for data security www.hss.state.ak.us/atac Core Principles Alaska Telehealth Advisory Council - Technical Standards Workgroup
  • ACKNOWLEDGEMENTS
    • Technical Expertise and Design
      • Tom Bohn
      • Jim Rogina
      • Chris Patricoski, MD
      • AFHCAN Statewide Committees
    • Funding Sources
      • DHHS - OAT
      • VA
      • U.S. Army
      • IHS
    • Legacy
      • NLM / UAA