1. The Role of Tele-health in the Management of Rural
Neuro-Emergencies Conference
September 14, 2012
Healthcare in a Perfect Storm:
A Time for Telemedicine & HIT
Dale C. Alverson, MD, FAAP
Medical Director, Center for Telehealth and Cybermedicine
Research, University of New Mexico
October 3, 2011
IT Medical Director, LCF Research
Albuquerque, New Mexico
Past President, American Telemedicine Association
Health Care Reform/PPACA Emerging Enabling Information
Communication Technologies
Economic Downturn
Need for more Access to Care
An Aging Population/Baby Boomers
Critical Shortage of Healthcare Providers
EHR Adoption/HIE
Meaningful Use
ICD10
PCMH
ACOs
A Time for Telemedicine & HIT
Major Public Health Issues Impacting our Rural
Communities and their Economic Development
Gaps in Access to Health Services
in Rural New Mexico
 Hepatitis C
 Behavioral Health
 Diabetes
 Asthma
 Cancer
 Oral Health
 Cardiac and
Stroke Care
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2. Critical Gaps in Health Expertise and
Services in New Mexico
 Mal-distribution of Providers
 Lack of Access to Health Services in Rural
Communities
 Only 3/33 counties
exceed the National average of physicians
per 100,000 population
 64% of physicians practice in 3/33 counties.
 These three counties comprise only 39% of New Mexico’s
Population
NMBME 2003
Mal-distribution of Health Specialty
Providers in New Mexico
The blue circles indicate
65 mile distances from
the 6 major specialist
centers
•Albuquerque
•Santa Fe
•Las Cruces
•Farmington
•Gallup
•Roswell
NMBME 2003
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Telehealth and
Health Information Technologies
are Part of the Solution in Closing the Gaps
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3. Defining Telemedicine and
Telehealth
1. “Tele-” comes from the Greek root word
meaning “distant or remote”/ “at a
distance”.
• Tele-phone
• Tele-vision
• Tele-graph
• Tele-scope
• Tele-Etc, etc, etc
How is Telehealth used?
 Clinical: Consultation, Direct patient Care, Case
Reviews
 Educational: Providers, Students, and Patients
 Research: Community-based Participatory, Outcomes
driven
 Administrative: Strategic planning, Operations
 Health Information Exchange
 Enhanced Disaster Response
Telehealth Networks
Rural/Remote Health Providers Can Access Expert Medical Opinions,
Knowledge, Education via Telehealth
Rural
or Remote Specialty
Location Telehealth
Network Medical Center
Audio
Patient High-Resolution Images & Video
Medical
Student
Local Health Consultation Specialist
Provider Direct Patient Care
Case Reviews
Education
Training
Health Information Exchange
Community-Based Research
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4. “Back to
the Future”
Case Reviews or Consultation
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5. ECHO: Treatment Outcomes
Outcome ECHO UNMH P-value
N=261 N=146
Minority 68% 49% P<0.01
SVR (Cure) Genotype 1/4 50% 46% NS
SVR (Cure) Genotype 2/3 70% 71% NS
SVR=sustained viral response
NEJM : 364: 23, June 9-2011, Arora S, Thornton K, Murata G, et.al.
Direct Patient Care
Maternal Fetal Medicine-High Risk Pregnancy
“Store and Forward”
 Capturing an image and storing it to then be forwarded for
review by a medical specialists
 Examples include teleradiology, telepathology and
teledermatology, tele-ophthalmology (retinal scans)
 “Telemedicine” or HIE?/Large Data Files Need Broadband
Teleradiology and Image Transfer Web‐Based Portals
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6. Video Phone or “VOIP” with video
Family Visitation
School Based Health Centers
Telehealth assistants at the school
or child care center provide the link
to examine the eyes, ears, throat,
lungs and skin.
Videoconferencing provides the
“face to face” interaction.
Getting providers to think of their
desktop computer as an exam
room is the trick.
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6

7. Trauma Triage
44% Transfer
Avoidance
27% Management
Recommendation
Changes
Moya M, Valdez J,
Yonas H, Alverson
DC. The Impact of
a Telehealth Web-
based Solution on
and Consultation.
Telemedicine and
eHealth, 2010;
16:945-949
IRA HAYES Project – PTSD/TBI
Telehealth
Toolkit
Skype
Videophone (H.324)
Software IP Based (H.323) Desktop IP Based (H.323)
Small Conference Room IP Based (H.323)
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8. Telehealth
Toolkit
SaaS (SIP)
Videophone (H.324)
Skype
Software IP Based (H.323)
Desktop IP Based (H.323)
Small Conference Room IP Based (H.323)
Hand Held Devices- “mHealth”
iPhone
Droid
iPhone
BlackBerry Treo/Palm
Smart Phones
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9. Remote Monitoring
The “Smart Band-Aid”
Geospatial Information Systems
(GIS) and Public Health
 Superimposing health data onto maps for enhanced
visualization
 Improves situational awareness and consequence
management
 Allows distribution of resources in a more targeted
manner, better mitigation of consequences, and improved
outcomes.
 A transdisciplinary collaborative approach between
experts in:
 GIS, modeling and simulation,
 public health
 health providers
Center for Telehealth and Cybermedicine Research
The Center for Telehealth
at UNM Health Sciences Center:
•Developing New Programs
•Technical, Operational,
Business, and Evaluation
Planning
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10. Http://www.lcfresearch.org
LCF Research’s Mission Statement
To improve the quality, access, and cost-effectiveness of health care
provided to the US population by conducting research in healthcare
delivery and public health, providing continuing professional
education, and advancing the meaningful use of health information
technology.
• Health Services Research and Development (HSRD)
• Health Information Exchange (HIE): NMHIC
• HIT REC: EHR Adoption, Achieving Meaningful Use
• Direct Secure Messaging (DSM)
•Task Force to Explore Expanding Access to and use of 28
Patient Information via NMHIC (TEAPIN)
How the NMHIC HIE Works
Clinician Requests Access to Patient Records with Patient Consent
EHR Gateway
State Public
Health Depts.
Hospital
Locates
the Patient’s
Records
Clinician
Patient NMHIC Office
HIE Network
Gathers & Lab
Assembles
the Patient’s
Records
Clinician Emergency
Room
Nationwide Health Information Network (NwHIN)
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Cloud Based
10

11. Cerner
Example Integration (Cerner)
Epic Example Integration (Epic)
Value/Benefits of HIE
 Access to each patient’s health information
 Improved situational awareness regarding patient’s
health and use of health systems, better
coordination of care
 Better triage and evaluation capability: Dx/Problem
list, prior procedures, Rx/Medications, Allergies,
tests; lab/x-ray
 Improved efficiency in making diagnosis and
management plans
 Decrease unnecessary duplication of tests
 Readmission avoidance
© LCF Research 2010 33
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12. ROI of HIE in ED
Humana WI: [A. Tzeel, MD, MHSA; et. al. American Health
& Drug Benefits l www.AHDBonline.com July/August
2011, Vol 4, No 4]
 Average savings of $29 per emergency department visit
compared with the control group. Decreased utilization of
imaging procedures and diagnostic tests drove this cost-
savings.
e.g. UNMH ED: 93,566 visits 2011 = $2.7 million
potential savings!
 Thus when clinicians utilize HIE in the care of patients who
present to the emergency department, the costs borne by a
health plan providing coverage for these patients
decreased.
 HIE obviates unnecessary service utilization through
provision of historical medical information regarding specific
patients at the point of care
© LCF Research 2010 34
The New Mexico Telehealth
Alliance
Telehealth Alliance
“Networks of Networks” Providers
Consumers
 Represents a consortium of
public and private health care Telehealth
stakeholders: “Neutral Expertise
Territory” (501c3)
Communication
Networks
 Reflects the diversity of our
health care delivery system in Social Networks
New Mexico
 Enables collaboration
New Mexico Telehealth Act
Passed and Signed into Law 2004
http://legis.state.nm.us
Introduced by Rep. Danice Picraux (D)
Supported by Sen. Susan Wilson-Beffort (R)
HOUSE BILL 581
46TH LEGISLATURE - STATE OF NEW MEXICO - SECOND SESSION 2004
Authorization Bill for Telehealth:
•Covers interactive video and “Store and Forward”
technologies
•Any Licensed Health Professional authorized to use
•Covers any Originating Site Where Patient Located,
including place of residence
•Authorizes/Encourages Use of and Reimbursement for
Telehealth
(NM Medicaid has announced policies to reimburse for
telehealth services)
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13. UNM and Other Healthcare Entities Have Established a Working IHS Taos Clinic
Telehealth Network in New Mexico through Collaboration Taos Public
Health Office
IHS Dulce
Clinic
Health Centers
Of NNM Raton Public
Health Office
UNM and Other Healthcare
Entities Have Established a Las Vegas
Working Telehealth Public Health
Network in New Mexico Office
through Collaboration
Health Centers
IHS Zuni Clinic Of NNM
First Choice
Albuquerque
South Valley SDCCHP
Adm. Office
First Choice-Edgewood
Hidalgo Medical
Services Albuquerque
Indian Health Service
Area Office
•Sangre de Cristo CHP
-SBIRT NM TechNet
-SBHC Albuquerque Office
•DOH
LCDF East Mesa
•DOC
Hidalgo Medical Already over 50
•UNM:
Services
-ECHO NM communities
-REACH LCDF Chaparral and over 200
•CHECS Net LCDF Anthony sites connected
LCDF Las Cruces and still growing
SBIRT partner sites
SWTAG is a “Network of Networks”
The 4 “C’s”
Cooperation
Coordination
Collaboration
Communication
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14. Telemedicine and
Licensure Portability
All of these Telehealth Technologies
and their Health Applications have
the potential for interstate use and
would benefit from licensure
portability
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15. The Elephant in the Living
Room
Credentialing and Privileging
Allowing by “Proxy”
The fundamental telemedicine question:
Who’s being transported to whom?
The provider to the patient or the
patient to the provider?
 If you transport yourself physically to a provider
in another state, you rely on their licensure,
credentialing and privileging in that state where
the provider practices
 The provider doesn’t need to be licensed,
credentialed and privileged in your state of
residence
 Why not the same for a telemedicine
transport?
Telemedicine and Need for
Interstate Licensure
 Information and Communication Technologies can
transcend state borders
 Provides a means to distribute and share limited
resources among states and fill gaps in access to
services and decrease health disparities
 Healthcare Reform will increase the demand for
primary and specialty services and telemedicine
can play an important role in meeting that demand
 Consumers of care will see the advantages of
accessing services independent of state borders
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16. Telemedicine and
Licensure Portability
 A more uniform system can enhance the interstate
CVS process and better insure effective monitoring,
patient safety, and quality of care without
compromising state medical board autonomy,
authority, and responsibility
 A Web-base system can improve efficiency and ease
of use (The “VetPro” model)
 Three elements are crucial for portability success:
1] Uniform online applications
2] Centralized credentialing
3] Faster processing
 Allow the option of Credentialing and Privileging “by
proxy” with appropriate CVS (TJC Model)
Liability and Risk Management
• Misuse
• Failure to use
• Becoming a Standard of Care
• Standards and Guidelines
http://www.americantelemed.org
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17. http://www.ctel.org/
http://www.telehealthresourcecenter.org/
American Telemedicine Association (ATA)
and Telemedicine
Hitting the Target: “The Triple AIMS”
Improve
Access
ATA
and ATA
Improve
Telemedicine Health
Reduce
Costs
International Telemedicine and eHealth:
Transforming Systems of Care in the Global
Community
Reasons to do International Telehealth
Most health issues are global!
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18. H1N1
H5N1
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19. Distributed Medical
Intelligence
• Knowledge Sharing
Networks/Just in
Time/On Demand
• Best Practices
• Evidence based
55
International
Union
Against TB
La Lancha Medica
en la Amazonia
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20. 58
59
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21. Exchange of Students and Faculty
Health Care Reform/PPACA Emerging Enabling Information
Communication Technologies
Economic Downturn
Need for more Access to Care
An Aging Population/Baby Boomers
Critical Shortage of Healthcare Providers
EHR Adoption/HIE
Meaningful Use
ICD10
PCMH
ACOs
A Time for Telemedicine & HIT
21

22. Navigating the Perfect Storm with
Telemedicine & HIT
Use a broad spectrum of information communication technologies
Effective distribution of limited resources and expertise
Increasing Access to care
Bringing care to the patient; Aging in place
Decreasing unnecessary variations in care; evidence-based best practices
Improving continuity and coordination of care;The Patient Centered Medical Home
Avoiding unnecessary hospitalizations, duplication of tests, & decreasing errors
Improving health outcomes
Reducing costs; avoiding more costly care and complications, decreasing travel
Questions?
http://hsc.unm.edu/som/telehealth
dalverson@salud.unm.edu
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