AFHCAN Project Stewart Ferguson, Ph.D Associate Project Director Director of Technology AFHCAN Project Office Alaska Nativ...
AFHCAN Sites
AFHCAN Partners <ul><li>IHS  - 194 sites - 97,000 beneficiaries </li></ul><ul><li>VA  - 1 site - 65,000 beneficiaries </li...
“Remoteness” by Access
Cost of Travel
“Types of Sites” by Staffing
NLM - Maniilaq Data <ul><li>11 Village clinics </li></ul><ul><li>Begin:  1/26/1999 </li></ul><ul><li>Gather: 1/15/2001 </l...
Lessons Learned from NLM... <ul><li>Software too difficult </li></ul><ul><ul><li>“ If you don’t use it regularly, then you...
Radio Medical Traffic <ul><li>Daily telephone calls </li></ul><ul><li>90 seconds / consult </li></ul><ul><li>Telemedicine ...
What is Telemedicine? “ Telemedicine involves the transfer of health data over a telecommunications system.” Ask-a-Doc Hom...
Workload Distribution
What are your key organizational goals for telehealth applications? Please rank in order of importance to your organizatio...
 
AFHCAN Referrals
 
AFHCANet <ul><li>Alaska Native Medical Center (1) </li></ul><ul><li>Veterans Administration Medical Center (1) </li></ul><...
 
 
VoIP - Anchorage Dial Tone <ul><li>Provide 24 dial tones in Anchorage </li></ul><ul><li>Integrate T1 into PBX at sites: </...
CLINIC NETWORK AFHCAN SYSTEM CART Otoscope ECG Scanner Touchscreen CPU UPS LAN Access Point Hub PRINTER Print Server Print...
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 Ser...
Sustainability <ul><li>Organization owns equipment </li></ul><ul><li>Training provided on: </li></ul><ul><ul><li>Assembly,...
1) Keep it Simple. <ul><li>Minimal computer skills </li></ul><ul><ul><li>Touchscreens </li></ul></ul><ul><li>High turnover...
2) Make it Sustainable and Supportable. <ul><li>Easily maintained </li></ul><ul><ul><li>Open source design   (.CFM) </li><...
So many organizations … so many software issues! <ul><li>>1000 Workstations </li></ul><ul><li>>100 Servers </li></ul><ul><...
A  properly designed  system can improve the quality of health care delivery  without saving  or sending a single byte.
Satellites <ul><li>Add 0.6 seconds to roundtrip delay </li></ul><ul><li>Cause web pages to load in 5 - 40 seconds </li></u...
 
Effect of Proxy / SSL
Alaska Federal Health Data Sharing Planned Project Relationships What the AFHCAN software is not ... VISTA CHCS T2P2 ? GCP...
AFHCAN Evaluation <ul><li>Usage - all </li></ul><ul><li>Evaluation questions - all </li></ul><ul><li>Voice over IP  - SEAR...
FAS Clinic (SCF) <ul><li>Team Approach - based on University of Washington’s nationally recognized model  </li></ul><ul><u...
FAS Clinic (SCF) <ul><li>Purpose - Develop diagnosis and treatment plan for FAS </li></ul><ul><li>Method - Interviews with...
PE Tubes
PE Tube Followup <ul><li>National standard - 4 month followups </li></ul><ul><li>Reality - 8 month or longer </li></ul><ul...
Develop standards to … ENHANCE the interoperability of disparate  telehealth systems and applications. IMPROVE the sustain...
ACKNOWLEDGEMENTS <ul><li>Technical Expertise and Design </li></ul><ul><ul><li>Tom Bohn </li></ul></ul><ul><ul><li>Jim Rogi...
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  1. 1. 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
  2. 2. AFHCAN Sites
  3. 3. AFHCAN Partners <ul><li>IHS - 194 sites - 97,000 beneficiaries </li></ul><ul><li>VA - 1 site - 65,000 beneficiaries </li></ul><ul><li>US Army, US Air Force - 9 sites - 47,000 military and dependents </li></ul><ul><li>USCG - 4 sites - 3,000 beneficiaries </li></ul><ul><li>Alaska PHN - 26 sites </li></ul>
  4. 4. “Remoteness” by Access
  5. 5. Cost of Travel
  6. 6. “Types of Sites” by Staffing
  7. 7. NLM - Maniilaq Data <ul><li>11 Village clinics </li></ul><ul><li>Begin: 1/26/1999 </li></ul><ul><li>Gather: 1/15/2001 </li></ul><ul><li>2863 Cases </li></ul><ul><li>8594 Images </li></ul><ul><ul><li>3393 Video otoscope (40%) </li></ul></ul><ul><ul><li>5061 Digital camera (60%) </li></ul></ul>
  8. 8. Lessons Learned from NLM... <ul><li>Software too difficult </li></ul><ul><ul><li>“ If you don’t use it regularly, then you will forget how to use it” </li></ul></ul><ul><li>Radio Medical Traffic </li></ul><ul><ul><li>“ 20 cases in 30 minutes” </li></ul></ul>
  9. 9. Radio Medical Traffic <ul><li>Daily telephone calls </li></ul><ul><li>90 seconds / consult </li></ul><ul><li>Telemedicine facilitates this process </li></ul>
  10. 10. 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
  11. 11. Workload Distribution
  12. 12. What are your key organizational goals for telehealth applications? Please rank in order of importance to your organization: <ul><li>Access to care </li></ul><ul><li>Patient Satisfaction </li></ul><ul><li>Quality of Care </li></ul><ul><li>Information Transfer </li></ul><ul><li>Costs/Economics </li></ul><ul><li>Continuity of Care </li></ul><ul><li>Other </li></ul>
  13. 14. AFHCAN Referrals
  14. 16. AFHCANet <ul><li>Alaska Native Medical Center (1) </li></ul><ul><li>Veterans Administration Medical Center (1) </li></ul><ul><li>Maniilaq Health Corporation (13) </li></ul><ul><li>SouthEast Regional Health Consortium (12) </li></ul><ul><li>Kodiak Area Native Association (6) </li></ul><ul><li>Eastern Aleutian Tribes (8) </li></ul><ul><li>Norton Sound Health Corporation (15) </li></ul><ul><li>Public Health Nursing (?) </li></ul><ul><li>Yukon Kuskokwim Health Corporation (47) </li></ul><ul><li>Bristol Bay Area Health Corporation (30) </li></ul><ul><li>Dialup connectivity (up to 23) </li></ul><ul><li>Commissioned - EAFB (1) </li></ul>
  15. 19. VoIP - Anchorage Dial Tone <ul><li>Provide 24 dial tones in Anchorage </li></ul><ul><li>Integrate T1 into PBX at sites: </li></ul><ul><ul><li>SEARHC, KANA, NSHC, MHC </li></ul></ul><ul><li>Least cost routing </li></ul><ul><li>Monitor traffic and cost savings: </li></ul><ul><ul><li>NSHC spends >$2000/mo </li></ul></ul><ul><ul><li>T1 cost ~$900/mo </li></ul></ul><ul><ul><li>24 dial tones ~$25/mo each </li></ul></ul>
  16. 20. 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
  17. 21. 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 <ul><li>CLIENT </li></ul><ul><li>Operating System </li></ul><ul><ul><li>Win95/98/NT/2000 </li></ul></ul><ul><ul><li>(Unix/XWindows) </li></ul></ul><ul><li>Browser </li></ul><ul><ul><li>IE v4.01/v5 </li></ul></ul><ul><li>Acquisition Hardware </li></ul><ul><li>Frame Grabber </li></ul><ul><li>Biometrics </li></ul><ul><li>SERVER </li></ul><ul><li>Operating System </li></ul><ul><ul><li>WinNT/2000 </li></ul></ul><ul><ul><li>(Unix/Linux) </li></ul></ul><ul><li>Web Server </li></ul><ul><ul><li>IIS, Apache </li></ul></ul><ul><li>Cold Fusion </li></ul><ul><li>Database Server </li></ul><ul><ul><li>SQL, Access </li></ul></ul><ul><li>Archive hardware </li></ul>
  18. 22. Sustainability <ul><li>Organization owns equipment </li></ul><ul><li>Training provided on: </li></ul><ul><ul><li>Assembly, testing, burnin </li></ul></ul><ul><ul><li>Software installation / management </li></ul></ul><ul><ul><li>Clinical design </li></ul></ul><ul><ul><li>Clinical usage </li></ul></ul>
  19. 23. 1) Keep it Simple. <ul><li>Minimal computer skills </li></ul><ul><ul><li>Touchscreens </li></ul></ul><ul><li>High turnover rates (re-training) </li></ul><ul><ul><li>Few choices per screen, color coded </li></ul></ul><ul><li>Language barriers </li></ul><ul><ul><li>Very selective word choice </li></ul></ul><ul><li>Disparate educational levels </li></ul><ul><ul><li>Reduce complexity to few components </li></ul></ul>
  20. 24. 2) Make it Sustainable and Supportable. <ul><li>Easily maintained </li></ul><ul><ul><li>Open source design (.CFM) </li></ul></ul><ul><ul><li>State Machine </li></ul></ul><ul><li>Centralize “Point of update” or “Point of Code” </li></ul><ul><ul><li>Web solution - NO custom clients </li></ul></ul><ul><ul><li>remote upgrades </li></ul></ul><ul><li>Minimize initial and recurring costs </li></ul><ul><ul><li>No ongoing licenses </li></ul></ul>
  21. 25. So many organizations … so many software issues! <ul><li>>1000 Workstations </li></ul><ul><li>>100 Servers </li></ul><ul><li>WinNT, Win2000, Unix, Linux </li></ul><ul><li>IE3, IE4, IE5, Netscape, Xwindows </li></ul><ul><li>POTS to T1 connectivity </li></ul><ul><li>Different patient encounter forms </li></ul><ul><li>RPMS / CHCS / VISTA / Meditech </li></ul><ul><li>Funds disappear in 2 more years </li></ul>
  22. 26. A properly designed system can improve the quality of health care delivery without saving or sending a single byte.
  23. 27. Satellites <ul><li>Add 0.6 seconds to roundtrip delay </li></ul><ul><li>Cause web pages to load in 5 - 40 seconds </li></ul><ul><li>Solutions: </li></ul><ul><ul><li>Remove need for frame sets </li></ul></ul><ul><ul><li>Caching locally </li></ul></ul><ul><ul><li>TCP/IP registry tweaks </li></ul></ul><ul><ul><li>Different IP stack </li></ul></ul><ul><ul><li>IE (http) registry tweaks </li></ul></ul><ul><ul><li>3rd party software (e.g. Flash Networks) - mostly proxy/spoofing techniques </li></ul></ul><ul><ul><li>3rd party hardware </li></ul></ul>
  24. 29. Effect of Proxy / SSL
  25. 30. 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
  26. 31. AFHCAN Evaluation <ul><li>Usage - all </li></ul><ul><li>Evaluation questions - all </li></ul><ul><li>Voice over IP - SEARHC, KANA, NSHC, MHC </li></ul><ul><li>PE Tube Followup - MHC </li></ul><ul><li>Video Conferencing - SEARHC </li></ul><ul><li>Ear Disease - YKHC </li></ul><ul><li>FAS Clinic - SCF </li></ul>
  27. 32. FAS Clinic (SCF) <ul><li>Team Approach - based on University of Washington’s nationally recognized model </li></ul><ul><ul><li>Pediatrician </li></ul></ul><ul><ul><li>Pediatric Psychologist </li></ul></ul><ul><ul><li>Physical Therapist </li></ul></ul><ul><ul><li>Speech and Language Therapist </li></ul></ul><ul><ul><li>Social Worker </li></ul></ul><ul><ul><li>Parent Navigator / Advocate </li></ul></ul><ul><ul><li>Clerk </li></ul></ul><ul><ul><li>Coordinator </li></ul></ul>
  28. 33. FAS Clinic (SCF) <ul><li>Purpose - Develop diagnosis and treatment plan for FAS </li></ul><ul><li>Method - Interviews with parent and child </li></ul><ul><li>Technology </li></ul><ul><ul><li>VtC (digital one way mirror) </li></ul></ul><ul><ul><li>Nikon 990 (dysmorphology) </li></ul></ul><ul><li>Future - travel team, travel equipment </li></ul>
  29. 34. PE Tubes
  30. 35. PE Tube Followup <ul><li>National standard - 4 month followups </li></ul><ul><li>Reality - 8 month or longer </li></ul><ul><li>Expect up to 90% of followups can be accomplished with reverse telemedicine </li></ul><ul><li>Is an image as good as an “on site” visit? </li></ul><ul><ul><li>Two independent “on site, in person” assessments. Take images </li></ul></ul><ul><ul><li>6 and 12 weeks later, conduct assessments from images alone. </li></ul></ul><ul><ul><li>Compare inter-provider variability, “on site” versus “image” assessment and treatment plans </li></ul></ul>
  31. 36. 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
  32. 37. ACKNOWLEDGEMENTS <ul><li>Technical Expertise and Design </li></ul><ul><ul><li>Tom Bohn </li></ul></ul><ul><ul><li>Jim Rogina </li></ul></ul><ul><ul><li>Chris Patricoski, MD </li></ul></ul><ul><ul><li>AFHCAN Statewide Committees </li></ul></ul><ul><li>Funding Sources </li></ul><ul><ul><li>DHHS - OAT </li></ul></ul><ul><ul><li>VA </li></ul></ul><ul><ul><li>U.S. Army </li></ul></ul><ul><ul><li>IHS </li></ul></ul><ul><li>Legacy </li></ul><ul><ul><li>NLM / UAA </li></ul></ul>

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