Telemedicine and Telehealth:
      The Virginia Telehealth Network
     and Virginia’s CAH-HITN Program

                 ...
Telehealth Defined

   Ideally, all healthcare encounters should be
    captured in a longitudinal multi-media electronic...
Virginia Telehealth Network (VTN)

                                                     The concept of VTN was spearheade...
Isolated Networks
                                                Hospitals



                                           ...
   The group’s meetings and planning became
    formalized with the incorporation of VTN in August
    2006

   In 2007,...
Unifying Strategy Adopted
                 in Spring 2007




          Public Health Problem Focus:
Many patients impacte...
Stroke Evaluation Targets
     for Thrombolytic Candidates
                                          Time
    Door to doc...
Fragmentation and
                                          Disparities of Care
             call
           volume




  ...
Scenario With Integrated Stroke System
      Patient (36 yo woman) experiences
      stroke symptoms. Family calls 911.
  ...
Sub-
                                                                              Sub-Acute
                             ...
Acute Stroke - “Telestroke”

              RP-7                                Images
                                    ...
34




                       Rural Telehealth
                         Challenges
    Weaknesses in health care manageri...
Rural Telehealth
                         Challenges




                                                          37




...
Questions?

             Kathy H. Wibberly, Ph.D.
Director, Division of Primary Care and Rural Health
           Virginia ...
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InTouch Health

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InTouch Health

  1. 1. Telemedicine and Telehealth: The Virginia Telehealth Network and Virginia’s CAH-HITN Program Kathy H. Wibberly, Ph.D. Director, Division of Primary Care and Rural Health September 23, 2008 1 What Is Telehealth?  Simply defined as:  The use of information and telecommunications technologies to distribute health services and education across or between health care systems. 2 Telehealth Defined  In reality, much more complex…  Telehealth is an organizational business practice using a combination of clinical, technical and business processes supported by policy, which policy, enables an health-related organization or health health- care institution to dynamically exchange electronic health information, health services and health education between providers, and/or providers and patients to facilitate the delivery of health care services. 3 1
  2. 2. Telehealth Defined  Ideally, all healthcare encounters should be captured in a longitudinal multi-media electronic multi- health record, however, few exist.  Related terms/fields: E-Health, Telemedicine, E- Informatics, HIT, and other forms of medical communications 4 Scope of Telehealth 5 Fit for Telehealth  Population- Population-based (seniors, children, immigrants, etc.)  Disease Management (chronic diseases, asthma, melanoma, mental health etc.)  Emergency Services (urgent and emergent care during a natural disaster or other crisis)  Diagnostic Interpretation & Treatment  Quality- Quality-Improvement (improving an existing service)  Cost Avoidance/Other System Benefit (decrease travel, reduce medical errors, reduce redundancy of medical tests, improve prescribing practices, etc.) 6 2
  3. 3. Virginia Telehealth Network (VTN)  The concept of VTN was spearheaded in 2002 by the Division of Primary Care and Rural Health  It began as an informal coming together of healthcare stakeholders sharing a common desire to address inequities in access to healthcare services using telehealth 7 Virginia Telehealth Network (VTN)  Historical approach to telehealth in Virginia  Applications designed and developed by each institution driven largely by reimbursement schemes  Clinical applications are VTC-based medical VTC- specialty consultations or tele-radiology tele-  No central focus on a particular health problem 8 Snapshot of Telehealth Equipped Sites in Virginia (December 2003) U.V.A. X= hub Community Service Board = point of presence (POP) V.D.H. Winchester D.O.C. Leesburg Arlington RAHEC Falls Church EVTN Woodstock Front Royal VA Dept. of Mental Health (VDMHMRSAS) Fairfax (2) Alexandria VCU. Manassas VT/VCOM Warrenton Harrisonburg Monterey Culpepper Fredericksburg Colonial Beach Dahlgren (2) (2) Craigsville Staunton Montross Mitchells Olney Warsaw Hot Springs Charlottesville St Stephens Church Accomac Bowling Green Callao Troy Clifton Forge Ashland (2) Heathsville Coving- Aylett Tappanahanock (3) Kilmarnock (4) Nassawadox ton Low Moor Goochland Glen Allen Dillwyn Saluda Belle Haven Franktown Lexington (2) (2) Vinton Lancaster New Castle Powhatan Richmond Grundy Lynchburg (11) Chesterfield Hartfield Blacksburg Roanoke Farmville (3) Charles City Cheriton Vansant (2) Madison Heights Petersburg Clintwood Salem X Bastion (2) Williamsburg Tazewell Christianburg Hayes Pound Pearsburg Blackstone Hampton Dungannon Cedar Bluffs Bland Newport News Wise Newport News Big Stone St. Paul Wytheville Radford Burkeville (17) Gap Lebannon Saltville Blacksville Catawba Portsmouth Norfolk Virginia Beach Pulaski Boydton Jarratt (3) 2-H Norton Marion Floyd Martinsville Abington (2) Hillsville Laurel Fork South Boston Pennington Gate City Konnarock Galax Suffolk Chesapeake Danville Gap Stuart Bristol 9 3
  4. 4. Isolated Networks Hospitals VCU VDH VT/VCOM Dept. of Corrections VDMHMRSAS/CSB UVA 10 The Birth of a Vision VT/VCOM VDH VCU VDMHMRSAS/CSB Other Networks Virginia Telehealth Network Dept. of Corrections EMS- Satellite Home health Provider UVA Geriatric patients offices facilities 11 Virginia Telehealth Network (VTN)  Early strategy for VTN (starting in 2004)  Population perspective - access issues and health disparities  Focus on infrastructure improvements without a p specific healthcare orientation 12 4
  5. 5.  The group’s meetings and planning became formalized with the incorporation of VTN in August 2006  In 2007, I 2007 VTN completed its formation by appointing l di f i b i i a Board of Directors and Executive Director – now pending 501c3 status expected by Dec 2008 13 Vision VTN believes that all Virginians should have access to high-quality healthcare regardless of their high- location — rural, urban or suburban-and that their suburban- health information should be securely shared among providers using technologies that support safe and timely care delivery when and where it is needed. 14 Mission VTN devotes its resources to advancing the adoption, adoption implementation and integration of telehealth and related technologies into models of healthcare statewide-- and promotes the integration statewide-- of health systems to support the delivery of care for all Virginians. 15 5
  6. 6. Unifying Strategy Adopted in Spring 2007 Public Health Problem Focus: Many patients impacted by stroke do not receive the most advanced stroke treatment possible. 16 http://www.cdc.gov/dhdsp/library/stroke_hospitalization_atlas.htm 17 Acute Stroke Care “TIME IS BRAIN” 18 6
  7. 7. Stroke Evaluation Targets for Thrombolytic Candidates Time  Door to doctor 10 minutes  Access to neurological expertise expertise* 15 minutes  Door to CT completion 25 minutes  Door to CT read 45 minutes  Door to treatment 60 minutes  Access to neurosurgical expertise* 2 hours  Admit to monitored bed 3 hours * By phone or in person 19 Fragmentation and Disparities of Care Virginia Hospitals by Stroke Center Designation 20 Fragmentation and Disparities of Care Board-Certified Neurologists in Virginia by Rurality 21 7
  8. 8. Fragmentation and Disparities of Care call volume EMS Time from Call to Arrival at Destination 22 Continuum of Care Framework 23 Scenario Without Integrated Stroke System Patient (36 yo woman) experiences stroke symptoms. Family calls Family physician, 30 min later office returns call instructs patient to call 911, volunteer EMS alerted from home, site arrival 36 min, transported to CAH ED within 3 hours of onset. • ED physician recognizes stroke symptoms, calls in Patient admitted to CAH Patient discharged from technician, orders CT, blood tests. floor bed – OT/PT CAH to home PT services evaluations completed; (inpatient rehabilitation • CT performed and read by general radiologist, who no speech pathologist facility preferred) rules out hemorrhage. available- aspiration • No neurologist is available so ED physician diagnoses available, pneumonia patient with acute ischemic stroke, but is uncomfortable treating with t-PA, [closing window] so elects to treat with aspirin and admit to floor bed Onset Onset Onset Onset 9.00 PM + 1 hour + 2 hour + 3 hour ALOS: 5.8 days* Pt unable to return to work – “laid off” – severe disability Adapted from May 2006 “Stroke Care of the Future” * Based on study results presented at ISC Feb 2006 Presentation with permission from SG2 24 8
  9. 9. Scenario With Integrated Stroke System Patient (36 yo woman) experiences stroke symptoms. Family calls 911. EMS completes F.A.S.T., and Education Improve glucose screening, instructs family to ride in ambulance; en route Stroke Physician Code is alerted at CAH ER, patient is Telemedicine consult Communication transported to CAH ED within 40 mins of initial call. PACS – immediate reading of CT Patient admitted to N- Patient discharged from • ED physician confirms stroke symptoms, radiology tech Community-EMS and lab tech in-house alerted –calls PSC page operator NICU Unit X 24 hrs – PSC to inpatient Stroke Unit rehabilitation, and back to • Neurologist RP7 communication initiated Speech/OT/PT home PT/OT services Education • CT performed and PACS to Stroke neurologist, who evaluations completed; EMR sent to PCP and MRI-DWI obtained – rules out hemorrhage referring ED physician severe carotid stenosis – • Neurologist reviews inclusion/exclusions for rt-PA ‘ pt has NS procedure trained ER nurses administer t-PA, trained ambulance next day crew transports Onset Onset Onset Onset Onset Onset 9.00 PM + 1 hour + 2 hour + 3 hour + 24 hour + 72 hour ALOS: 3.8 days* Pt returns to vocation as clerk (supporting family of 3) 25 Adapted from May 2006 “Stroke Care of the Future” * Based on study results presented at ISC Feb 2006 Presentation with permission from SG2 CAH- CAH-HITN Grant VAST- VAST- Phase 1 Pilot  Being leveraged to set-up the VAST test-bed across set- test- the Central Shenandoah Region focusing on Bath Community Hospital as the CAH.  Design, implement, test and evaluate an integrated and fully optimized stroke network that can be replicated state-wide state-  Eventual goal is to leverage the infrastructure to support other healthcare needs– starting with the co- needs– co- morbidities of stroke (CAD, HTN, Obesity etc) 26 Virginia CAH-HITN Partners CAH- 27 9
  10. 10. Sub- Sub-Acute EMS Care & Notification Acute Secondary Prevention/Education & Response Treatment Prevention Rehabilitation Continuum of Care Continuous Quality Improvement (CQI) Interventions Interventions Interventions Virginia Stroke Systems Website EMS Stroke Plan PACS Patient/Family/Provider Toolkits EMD/EMT Stroke Remote Consultation Protocols Social Marketing Campaign Clinical Protocols Web-based Learning National Tele-stroke Conference Management System 28 Prevention/Education Interventions  Virginia Stroke Systems Website  http://virginiastrokesystems.org  Content Management System V d Vendor: W d il St di Woodpile Studios  VAST Toolkits (Family, Community)  Stroke Social Marketing Campaign  National Telestroke Conference in Northern VA  Dec 9-10, Co-sponsored by the American 9- Co- Telemedicine Association 29 EMS Interventions  Regional EMS Stroke Plan  Enhanced Stroke Protocols  911 Emergency Medical Dispatch  EMS- First Responders EMS-  Improved EMS Documentation  Web-based learning management Web- system  Vendor: 30 10
  11. 11. Acute Stroke - “Telestroke” RP-7 Images transmitted Live Image of Patient in Rural CT Scan Remote Site Hospital as Seen (Note image of By Physician in physician as a “Stroke Center” part of the 2-way transmission) 31 RP7 Robot “Remote Presence”  InTouch Health – deployed now at UVA-BCH UVA- ~5 foot – 200 lbs – 150 “eyes” – infrared sensors 32 Critical Access Hospitals with RP Technology CAH locations 33 11
  12. 12. 34 Rural Telehealth Challenges  Weaknesses in health care managerial culture  Lack of understanding of HIT value/benefits by Providers/Patients  Reimbursement & Capital Costs p  Aligning Financial Incentives  Driving Cost-Effectiveness (i.e. Chronic Care & Cost- Disease Mgmt)  Start-up Costs Capital Investment Start-  Standards (Clinical & Communications)  Quality & Safety 35 Rural Telehealth Challenges  Infrastructure Issues  Inadequate and/or Costly Network Infrastructure / Broadband Access  Interoperability p y  Human Dimension Issues  Arrangements to Practice in an e-enabled e- Environment  Practitioner and Patient Acceptance  Licensure, Accreditation, Certification  Legal (Stark Law, Liability, FDA, HIPAA)  Training an HIT Workforce 36 12
  13. 13. Rural Telehealth Challenges 37 Summary  Telehealth/telemedicine is a growing component of the health care process and offers solutions to problems regarding resources and distances.  VTN has been established in Virginia to facilitate the systematic growth of telehealth/HIT—starting telehealth/HIT— with VAST.  CAH- CAH-HITN grant has been instrumental in allowing Virginia to achieve goals and objectives for VAST Phase 1 and helping VTN become established as an HIT leader 38 VTN Website: http://Ehealthvirginia.org 13
  14. 14. Questions? Kathy H. Wibberly, Ph.D. Director, Division of Primary Care and Rural Health Virginia Department of Health (804) 864-7426 864- Kathy.Wibberly@vdh.virginia.gov 40 14

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