Stewart ferguson afhcan

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Stewart ferguson afhcan

  1. 1. The AFHCAN Telehealth Program Stewart Ferguson, PhD Chief Information Officer (CIO) Alaska Native Tribal Health Consortium  Context  The Role of Telemedicine  Impact of Telemedicine  Financial Model for Telemedicine  The Future Alaska Native Tribal Health Consortium 1
  2. 2. ALASKA• 1st in land mass – 1,420 miles (N-S) – 2,400 miles (E-W)• 33,900 miles of shoreline – More than all of the contiguous National Travel and states combined. Safety Board (NTSB) reported 436• 47th in road miles commuter aircraft – 75% Alaskan communities unconnected by accidents in Alaska a road to a hospital. from1990-2004 (2.8 – 25 of these have no airport. accidents a month) - accounting for 36% of all commuter• Population density is 1.1 persons/mile2 aircraft accidents in – 70 times smaller than the national average. the US. Alaska Native Tribal Health Consortium 2
  3. 3. ALASKA’s PHYSICIANS• 49% of all physicians in Alaska are primary care physicians (2002 data). U.S. average is 28%• Alaska is 48th in “doctors to residents” ratio – 65% are located in Anchorage – Shortages in many specialties – 579 Community Health Aides in 200 villages provide nearly ½ million encounters each year. AI/AN U.S. Gap DISPARITIES: MD 73.9 220.6 66% LowerHealth Staff per DD 24.0 61.8 61% Lower100,000 people Nurse 229.0 849.9 73% Lower Alaska Native Tribal Health Consortium 3
  4. 4. Rural residents travel an average of 147 miles one way for access to next level of care. Point Hope Kotzebue Chicago Ann Arbor Anchorage Washington DC Alaska Native Tribal Health Consortium 4
  5. 5. CONTEXTALASKA NATIVES ARETHE HEALTHIEST PEOPLEIN THE WORLDANTHC VISION Alaska Native Tribal Health Consortium 5
  6. 6. Years of Potential Life Lost, Alaska Natives, 2004-08 Unintentional Injury (n=451) Suicide (n=250) Cancer (n=555) Heart Disease (n=328) Chronic Liver Disease (n=114) Homicide (n=56)Cerebrovascular Disease (n=70) Pneumonia/Influenza (n=35) COPD (n=96) Diabetes (n=39) n=number of deaths before age 75 years 0 5000 10000 15000 20000 Source: Alaska Epidemiology Center, Alaska Native Tribal Health Consortium ANTHC; Alaska Bureau of Vital Statistic
  7. 7. Alaska Native Tribal Health Consortium
  8. 8. Historically, Alaska Native and Canadian First Nationspopulations have been burdened with a highprevalence of otitis media and associated morbidity.The incidence of ambulatory care visits related to otitismedia for American Indian and Alaska Native childrenis twice that for all U.S. infants.The placement rate for tympanostomy tubes in thesechildren less than age five was 20 times higher inAlaska compared to the continental U.S. Alaska Native Tribal Health Consortium 8
  9. 9. Alaska Tribal Health System• The Indian Health Service funds only about 65% of the level of need.• The tribal organizations must fund-raise to obtain sufficient funds to provide quality care. – Uncompensated care impacts the ability of these health care systems to provide care to their beneficiaries as well as others. Alaska Native Tribal Health Consortium 9
  10. 10. Designing A Primary Care Tool • Ear Disease – Audiometer, Tympanometer, Video 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 Alaska Native Tribal Health Consortium 10
  11. 11. A User Interface Designed by Users 11 Alaska Native Tribal Health Consortium
  12. 12. AFHCAN Telehealth Program Cases Created per Year  Managed by ANTHC  Federally funded 35,000 30,000 25,000  28 StaffCases Created 20,000 15,000 10,000  11 year Operational History 5,000  33,000 cases/year 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011  131,628 Cases (ATHS) Installed Customer base includes:  Alaska: 248 sites, 44 organizations 59 operational systems in 2011 1,443 providers in 2011 22,763 patients in 2011 (16% of AN pop)  Other states and countries Alaska Native Tribal Health Consortium 12
  13. 13. THE ROLE OF TELEMEDICINE Alaska Native Tribal Health Consortium 13
  14. 14. We only assumepatients travel tonearest region Alaska Native Tribal Health Consortium 14
  15. 15. Audiology Cardiology Care Coordination Role of Telemedicine Center Dental Dermatology Emergency• S&F • VtC Department Endocrinology – 3% of encounters – Cardiology Family Medicine – Primary Care (75%) – Liver/Hepatitis Gastroenterology HIS – Specialty Care (25%) – Pediatrics Internal Medicine Neurosurgery – Triage / Planning – Breast Cancer Opthalmology – Discharge Planning Screening Orthopedics Otolaryngology – Esoteric : Abuse … – Mental Health / API Pediatrics- Outpatient Podiatry Pulmonology – Teleradiology • RPM Rheumatology – Telepharmacy Surgery Urology Women’s Health Alaska Native Tribal Health Consortium 15
  16. 16. By the numbers … 131,628 Cases created 65,314 Patients served 2,968 Providers involved 1,854 Providers creatingATHS (Alaska Tribal Health System)(1/1/2001 to 3/31/2012) Alaska Native Tribal Health Consortium 16
  17. 17. IMPACT OF TELEMEDICINE Alaska Native Tribal Health Consortium 17
  18. 18. Why do you do 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% • Best for patient care • Increased access for care Alaska Native Tribal Health Consortium 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 Alaska Native Tribal Health Consortium 19
  20. 20. Joslin Vision Network (JVN) Portable JVN Pilot Deployment of the IHS-JVN in Alaska using a portableplatform reversed a seven year decline in rates for the state 70% 15% Increase 60% 50% DR Exam Rate 40% 30% 25% Decrease Portable JVN 20% implemented 10% 0% Alaska Native Tribal Health Consortium 20
  21. 21. Pre-Operative Planning for Ear Surgery Using Store-and-Forward Telemedicine John Kokesh M.D., A. Stewart Ferguson Ph.D., Chris Patricoski M.D. 40% The average 35% difference was not Percent of Patients 30% statistically 25% different between 20% NonTelemed the two groups: 15% Telemed 32 minutes for the 10% telemedicine 5% evaluation group 0% and 35 minutes -3 -2.5 -2 -1.5 -1 -0.5 0.5 1 1.5 2 2.5 3 for the in-person Actual Surgical Time - Planned Surgical Time (hrs) evaluation groupComparison of surgical time (actual surgical time – estimatedsurgical time) for telehealth and non-telehealth cases. Values in theright half of the plot represent cases which took longer than planned (42% of telehealthcases and 47% of non-telehealth cases); values in the left half represent cases thattook less time than planned (58% of telehealth cases and 53% of non-telehealthcases) Alaska Native Tribal Health Consortium
  22. 22. 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 Alaska Native Tribal Health Consortium 22
  23. 23. Speed of Reply Turnaround Time 1 Day Same Day 4 Hour 2 Hour 1 Hour 100% 91% 80% 73%% Cases 60% 59% 40% 43% 28% 20% 0% Alaska Native Tribal Health Consortium 23
  24. 24. How important is the speed of reply? (% “Extremely Important) When using AFHCAN for patient care – how important is the speed of reply of the consulting doctor? 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% High User (Initiator) High User (Consultant) Medium User (Initiator) Medium User (Consultant)• Speed of response is clearly more important to Initiators compared to Consultant• High User Initiators - 43% rated this 5 out of 5 (“Extremely Important”) Alaska Native Tribal Health Consortium 24
  25. 25. THE FINANCIAL MODEL FOR TELEHEALTH Alaska Native Tribal Health Consortium 25
  26. 26. Medicaid-Eligible PatientsMedicaid Medicaid Paymentspayments $70,000totaled $60,000$269,893 to $50,000 $40,000ANMC for $30,000specialty $20,000 $10,000telehealth $0consults. 2003 2004 2005 2006 2007 2008 2009 A total of 5,925 telehealth specialty consults with provided to 3,663 unique patients. Alaska Native Tribal Health Consortium 26
  27. 27. We only assumepatients travel tonearest region Alaska Native Tribal Health Consortium 27
  28. 28. Medicaid Study: 2003-2009 Decreased Travel = Cost Savings Quantity CostClaims Paid by Medicaid 4,482 ($269,894)Telemedicine Prevented Travel 3,662 $3,116,034 Notes: • Travel is saved for 75% of all patients. • Assume all patients under 18 need an escort • Travel costs based on 1 week advance faresNet Savings Realized by Medicaid $2,846,140 Note: For every $1 spent by Medicaid on reimbursement, $10.54 is saved on travel costs. Outreach clinics saved another $3.4m in travel costs Alaska Native Tribal Health Consortium 28
  29. 29. In FY11, 301 pediatric patients weretransported from the YKHC by LifeMed at a cost to Medicaid of $2.86 million Average cost: $9494 per patient Telehealth may prevent 20% of such transports Alaska Native Tribal Health Consortium 29
  30. 30. In FY11, the total amount spent on non- emergent medical travel and accommodation for all IHS patients in Alaska was $38.6 million Patients aged 0-18 years accounted for53.7% of all travel & accommodation costs statewide Alaska Native Tribal Health Consortium 30
  31. 31. THE FUTURE Alaska Native Tribal Health Consortium 31
  32. 32. The New Limiting Step Alaska Native Tribal Health Consortium
  33. 33. Growing Usage100%90%80%70% High & Medium Users (11 YR) n=1460% High & Medium Users (10 YR) n=1050%40% High & Medium Users (9 YR) n=630%20% High & Medium Users (8 YR) n=510% 0% 100% 1 2 3 4 5 6 7 8 9 10 90% 80% 70% High & Medium Users (10 YR) n=8 60% High & Medium Users (9 YR) n=13 50% 40% High & Medium Users (8 YR) n=5 30% 20% High & Medium Users (7 YR) n=4 10% 0% 1 2 3 4 5 6 7 8 9 10 Alaska Native Tribal Health Consortium 33
  34. 34. Improve Performance with Scale Cases Created per Year 4,000 • Good will and 3,500 3,000 commitmentCases Created 2,500 2,000 • Earned time off for 1,500 1,000 volume done 500 0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 • Provider time allocated (Proj) to telemedicine Median Turnaround Time (hrs) 3.5 • Financial incentive to Median Turnaround Time (Hrs) 3.0 2.5 do the “additional” 2.0 1.5 work 1.0 0.5 0.0 2010 Q4 2011 Q1 2011 Q2 2011 Q3 2011 Q4 2012 Q1 Alaska Native Tribal Health Consortium
  35. 35. The Commoditization of Telehealth• Telehealth will part of a blended health visualization – Video, Audio, Health Record, Images, Devices• Lightweight commodity platforms – Portable, direct to desktop – Integrated into local EHR – HTM will evolve to smart systems, full integrated• Leverage large scale infrastructures e.g. MPI Alaska Native Tribal Health Consortium 35
  36. 36. Technology is a STRATEGY toimprove performance and to manage costs & risk
  37. 37. Pay for Value• Simplified Fee Structures – Existing coding poor match• Business models will move well past “fee for service” concepts - eVisits, employee plans, systemic approaches.• Fee for Service will not be as relevant. Bundled case management plans and other plans make more sense. Alaska Native Tribal Health Consortium 37
  38. 38. Drivers for Different Business Models• Telehealth is only a financially viable solution at scale• Scale is HARD. – Few models for maximizing performance at scale – May drive Buy versus Build  outsourced care• Need risk avoidance models e.g. ACO, HMO• Demand will continue to outstrip resources – Non traditional usage models for efficiency gains – Innovative pilot models needed – opportunity exists• Market differentiator – Empower consumers• Need business models NOT based on reimbursement Alaska Native Tribal Health Consortium 38
  39. 39. sferguson@anthc.orgAlaska Native Tribal Health Consortium

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