CENTER for DISTANCE HEALTH

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CENTER for DISTANCE HEALTH

  1. 1. Center for Distance Health Curtis L. Lowery, M.D. Director, ANGELS Program Professor and Chairman Department of Obstetrics and Gynecology College of Medicine University of Arkansas for Medical Sciences (UAMS) Nov 2008
  2. 2. CDH Presentation Objectives Overview Projects Launched in 2007-08 Brief Review of Programs Conclusion
  3. 3. CDH Overview The Center for Distance Health (CDH) is located within the College of Medicine. It allows the University of Arkansas for Medical Sciences (UAMS) to respond to the demands for health care in traditional and non-traditional pathways.
  4. 4. CDH TELEMEDICINE
  5. 5. Telemedicine Projects Launched Arkansas SAVES “ TeleStroke” Telenursery Telehealth KIDS –Lee County School Prison Telemedicine Neurology Cardiology Mental Health / Substance Abuse Child Advocacy Program
  6. 6. 1233 TELEMEDICINE CONSULTS January-September 2008 > 10% no show rate
  7. 7. Increases patient catchment area Decreases no-show rate No travel for clinicians providing outreach services Local healthcare access for patients CDH Telemedicine Sites
  8. 8. CDH TRAINING
  9. 9. CDH Training Center Worldwide Host for Telemedicine Training
  10. 10. Resident Technology Training Residency Evaluation Observing resident/Patient interaction Residency Telemedicine Conducting consult clinics Residency Completion Supports physicians who decide to practice in rural setting
  11. 11. Hospital preparedness Training CDH Trainers facilitate training for the statewide EMS system CDH Trainers provide equipment training to all 86 Hospital in the state
  12. 12. CDH EDUCATION
  13. 13. Distance Education Projects Launched OB Case Conference OB/GYN Grand Rounds Peds PLACE FAIM ONE TEAM Neurosurgery Conference Support Obesity Case Conference
  14. 14. September OB-GYN Grand Rounds 09/03/08Wilbur Hitt, MD Minimum Invasive Surgery 09/17/08 Mary Pat Hardman, MD Pediatric & Adolescent Gynecology 09/24/08 Teresita L. Angtuaco, MD OB/GYN Imaging: An update
  15. 15. 9/4/08 The Collaborative Critical Care Research Network access to a national resource (Sunny Anand, MD) 9/11/08 Sudden Death in Children (Brian K. Eble, MD) 9/18/08 Case Presentation: Atypical Kawasaki's (Perry Wilbur, MD) 9/25/08 Asthma - telemedicine school project (Drs. Vogle, Hadley, Bynum, Burke) Peds PLACE September 2008
  16. 16. Peds PLACE Physician Learning And Collaborative Education A Presentation by: R Whit Hall, MD Other Contributors: Chris Smith MD, Bryan Burke MD, Julie Hall-Barrow EdD, Rachel Ott, BA
  17. 17. BackgroundPeds PLACE: Pediatric Physician Learning And Collaborative Education Needs: Continuing education for rural practitioners Translational research interpretation Relationships built between academic medical center and practicing clinicians
  18. 18. Description of Interaction Weekly, one-hour interactive teleconference Participants: University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, and state’s practicing clinicians Neonatology: One Week General Pediatrics: Two – Three Weeks Translational research: One Week
  19. 19. Information Flow Bench to Bedside Bedside to Community Bench Research
  20. 20. Educational Format Assign topic with volunteers Interactive format No lecturer, only discussant Limit presentation to 20 slides Guidelines once monthly
  21. 21. Technology Employed Originating site: Video, audio camera TV screen Cable: 750 kb/sec Distant site: Video, audio camera TV screen
  22. 22. Topics Past topics focused on… Patient recruitment from local communities because of limited subject availability New translational research data of general interest to community physicians Examples: Relationship of Hypercarbia to intraventricular hemorrhage in preterm newborns and enhancing appropriate perinatal referrals to perinatal hospitals
  23. 23. Satisfaction Study Sixteen Peds PLACE participants were asked to respond to the following questions. Responses follow.
  24. 24. Satisfaction Study I am comfortable consulting a physician at UAMS/ACH with questions concerning the care of my patient(s) during Peds PLACE. 0 10 20 30 40 50 Strongly Disagree Disagree No Opinion Agree Strongly Agree
  25. 25. Satisfaction Study 0 20 40 60 80 Strongly Disagree Disagree No Opinion Agree Strongly Agree I find Peds PLACE relevant to my practice.
  26. 26. Satisfaction Study I will change my practice to conform to Peds PLACE recommendations. 0 2 4 6 8 10 Strongly Disagree Disagree No Opinion Agree Strongly Agree
  27. 27. Satisfaction Study Of the 16 participants, 62% preferred Peds PLACE’s interactive format over lectures and journals to gain Continuing Medical Education.
  28. 28. Conclusion Translational research can be facilitated with telemedicine to community physicians if it is combined with an educational program, as demonstrated through Peds PLACE.
  29. 29. Questions? For More Information: http://www.uams.edu/angels or HallRichardW@uams.edu
  30. 30. FAIM Fetal Anomaly Interdisciplinary Management September 26, 2008 Perinatal Infections Nafisa Dajani, MD
  31. 31. Academic Affairs Distance Education Beginning July 2008 CDH provides network support to all UAMS’ interactive video education classes
  32. 32. Projects In Development High-Risk Infant Monitoring Pilot Tele-ER Tele-PICU Museum of Discovery Geriatrics
  33. 33. Projects Planned Geriatrics Sexual Abuse Division Newborn Screening Regional Pediatric Clinic Sites
  34. 34. Brief Review of Related Programs
  35. 35. Regionalization of Neonatal Care in Arkansas
  36. 36. Objectives • Background • Rationale • Plan • Benefits COBRE Community Based Research and Education National Center for Research Resources Core Facility 6-6-07
  37. 37. Background: What we do now • Bench to bedside – Meetings, lectures, abstracts, journal clubs, specialties with multiple areas of interest (Good) • Bedside to curbside – Articles, communication with pharmaceutical reps, subspecialists (OK) • Curbside to patient care (Poor) NIH Initiatives to Implementation Research Duane Alexander, PAS 2007
  38. 38. Background: The problem • Bedside to curbside • Curbside to patient care The solution: Regionalization of Care Through • Education • Telemedicine • Connection
  39. 39. Background Regionalization: Assessment of AR newborn care to date • Assess current mortality, morbidity, and costs of academic vs. community care • Assess increased dissemination of evidence based guidelines and research to community physicians through obstetric and neonatology conferences We know what to do; we don’t know how to do it
  40. 40. USA data • 60,000 babies <1500 grams (VLBW) • 20,000 babies <1000 grams (ELBW) • Rate of preterm delivery increasing – Causes are multifactorial, social – No changes in preterm delivery rate or survival Changes needed will be in better organization of newborn care Pediatrics, 2005
  41. 41. Arkansas data • Underserved and 43% rural • Levels of care undesignated • UAMS: Sole hospital with perinatal coverage providing delivery service • ACH: Free standing Children’s Hospital • Both supported by same neonatology service
  42. 42. Arkansas has 73 of 75 counties designated as medically underserved areas, with much of Arkansas facing a healthcare provider shortage. 42nd in the nation in neonatologists © AR Dept. of Health and Human Services, 2006 Arkansas Demographics
  43. 43. • Regionalization and maternal transport improve outcomes in smallest babies • Intensive newborn care provides money and prestige to hospitals, leading to deregionalization • Inappropriate referrals lead to overcrowding at referral center Textbook of Neonatology by Fanaroff, 2004 Maternal Transport in Arkansas: Maldistribution of Care
  44. 44. Methods used in COBRE to date • Medicaid records – Matched birth records, death certificates with hospital records • 91% match • Outside data analysis • Cooperative Medicaid administration • Analyzed mortality, morbidity, and costs
  45. 45. Finding 1: Improved Survival for High-risk Infants 0% 5% 10% 15% 20% 25% 30% 35% 40% 500-999 grams 1000-1499 grams 1500-2499 grams UAMS Other hospitals with NICU Hospitals without NICU Risk of Death within 60 days after Birth, by Delivery Hospital and Weight P<0.01 P<0.05 P>0.10 Data is consistent with a recent NEJM report (Phibbs CS et al, 2007)
  46. 46. 0 5 10 15 20 25 30 500-750g 751-1000g 1001-1500g All UAMS ACH Comparison of grades 3 and 4 intraventricular hemorrhage for UAMS (inborn) vs ACH (outborn) neonates for 2001-2004 P<0.01, UAMS vs. ACH at all weights Percent Finding 2: Better Neurodevelopmental Outcome for Inborn Delivery Data from Medicaid 2003-2004
  47. 47. Finding 3: Costs of IVH 0 100000 200000 300000 400000 500000 600000 500-750 750-1000 100-1250 1250- 1500 IVH No IVH Total Medicaid costs over 4 years, 2001-2004
  48. 48. Finding 4: Costs of Newborn Care • Average cost per patient • Costs include Medicaid charges over 12 months – Inpatient hospital, outpatient hospital, homecare, prof services, drugs, other services 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 160,000 <1000 grams 1000-1500 grams UAMS Hosp NI Hosp w/o NI $ per year per pt Average cost per year per pt over 2500 grams: $3723 Data from Medicaid 2001-2004
  49. 49. Problem 2: NICU Follow-up • Increase in VLBW survival • Medically fragile population • Increased hospital costs
  50. 50. Finding: Medicaid Costs in AR • 87 Medicaid recipients cost $7,955,333 • Outpatient costs: $18,330 compared to $1,447 • Higher mortality • Increased hospital admissions Data from Medicaid, 2001-2004
  51. 51. The Solution: Education • Phase I – Peds PLACE (Physician Learning and Collaborative Education) – A weekly tele- conference engaging pediatricians and family practitioners across the state to discuss common pediatric issues. – Cased based presentations and evidence based guidelines are core components to the conference. – Peds PLACE provides a forum for topic discussion as well as building relationships with academic and practicing physicians.
  52. 52. The Solution - Telemedicine • Phase II – Telemedicine units in the largest nurseries in the state. – Hospitals with NICU to participate in 8:15 conference (MWF) – Began March 2008 with ACH, UAMS, Medical Center of South AR, Washington Regional, Willow Creek, St. Edwards Mercy. – Beginning June 2008 – Wadley and St. Bernards • Existing data, census data, transport consultations
  53. 53. The Solution - Telemedicine • Resuscitation • Major medical decisions • X-ray interpretation • 24/7 connectivity with neonatology for consultation
  54. 54. The Solution: Telemedicine • Sustainability – ACH to keep referrals long term – Help wide swings in census – Rural hospital will be able to keep more patients – Medicaid to save money on transports – It’s the right thing to do
  55. 55. Potential Barriers • Technological difficulties – Maintenance at remote and central site • Physician reluctance to change – Monetary incentives for local champion • Central reluctance to assess by telemedicine – Currently done by phone
  56. 56. Guidelines • Case based • Evidence based with references • Community physician buy-in • Periodic review
  57. 57. Strengths available in AR to accomplish and evaluate goals • T-1 lines capable of carrying 1.5 megs/sec (bioterrorism after 9/11) already in place to every hospital and ER in the state to allow live videoconferencing • Educational telemedicine already established with IT support available in remote sites • Medical home at ACH and central 24/7 telephone triage system in place • Willingness of pediatric section to support remote sites
  58. 58. Benefits • Facilitate regionalization • Case management of high risk newborn follow-up • Enhance grant funding – HRSA – Medicaid Transformation – ATT • Encourage translation of research • Strengthen CTSA application – Ask not what CTSA can do for you………
  59. 59. Thanks, RR020146 • Release time • Equipment • Mentoring “ ‘Tis better to curse the darkness than to light the wrong candle” Joe, Fireworks factory
  60. 60. Professional Education • High Risk OB Case Conference – Occurs weekly – Physicians • Neonatal Case Conference – Monthly – Physicians – Pediatricians and Neonatologists
  61. 61. Professional Education • ONE Team – Obstetrical Nurse Exchange – Occurs monthly – Nurses – Additional neonatology nurse exchange will be added within 3 months • Pediatric Case Conference – Arkansas Children’s Hospital
  62. 62. Professional Education • STABLE • Basic and Advanced Fetal Monitoring • Nursery Nurse – 8 part series
  63. 63. Staff Education • Ethics Conference – Monthly – All healthcare professionals • Billing – Outpatient – Billing
  64. 64. Public Education • Bereavement Support Group – monthly • Parenting Courses – quarterly • Childcare Worker Courses – quarterly • Diabetes Management – Pilot Grant • Smoking Cessation – Annually
  65. 65. Who are we reaching? 2006 Data • High Risk OB – 1393 • Neonatal – 91 • ONE Team – 133 • Professional and Staff Education • 272 total programs offered • Physicians 1411 • Nurses attending 2836 • Others attending 1565
  66. 66. Physician Call Center Facilitating Physician to Physician consults Facilitating Physician to Physician Patient Transports
  67. 67. FCC – Statewide Telemedicine Network ATOM FCC supports UAMS to the sum of $4,217,688 in achieving the goals of consolidation, expansion, and management of the Arkansas Telehealth Network.
  68. 68. Obstetrical Guidelines Neonatal Guidelines Pediatric Guidelines Total 95 Total 41 Total of both OB and Neonatal = 137 guidelines BEST PRACTICE GUIDELINES
  69. 69. Research Opportunities •CTSA Submission Oct 2008 interwoven with Distance Health •ANGELS Medicaid Claims Birth Certificate analysis • Other Program Research
  70. 70. Recent Awards 09/16/08 Nurse Practitioner’s in Women’s Health Inspirations in Women’s Health Award Gordon Low, APN 10/07/08 Rural Telecommunications Congress People’s Choice Award Curtis Lowery, MD / ANGELS
  71. 71. CENTER for DISTANCE HEALTH
  72. 72. Arkansas SAVES Stroke Assistance through Virtual Emergency Support Julie Hall-Barrow, EdD
  73. 73. Program Acknowledgements • Arkansas Department of Human Services • Arkansas Department of Health • UAMS Center for Distance Health – Curtis Lowery, Director – Tina Benton, Clinical Division Director – Salah Keyrouz, AR SAVES Medical Director – Margaret Tremwel, AR SAVES on-call Neurologist • Governors Acute Stroke Task Force
  74. 74. Background • 700,000 stroke/year – 500,000 first attacks – 200,000 recurrent attacks • Incidence in men >women • Incidence is higher in African American and Hispanics • 3rd leading cause of death
  75. 75. Background • Stroke Type – Ischemic Stoke – Intracerebral Hemorrhage – Subarachnoid Hemorrhage 88% 9% 3%
  76. 76. Background - Mortality • 30 day mortality after stroke – Intracerebral hemorrhage • 38% dead 62% alive – Ischemic stroke • 12% dead 88 alive • Mortality higher in women, minority
  77. 77. Background - Aftermath • Leading cause of serious, long-term disability • 14% will have another stroke within 1 year • 15-30% are permanently disabled • 20% require institutional care at 3 months
  78. 78. Background - Cost • Estimated direct and indirect cost in 2006: $57.9 billion • Average 30 day cost of a mild ischemic stroke is $13,019; severe ischemic stroke $20,346 • Mean lifetime cost of an ischemic stoke estimated at $104,048
  79. 79. Arkansas SAVES: Why Arkansas?• First nationally for stroke mortality. • 7,534 heart disease-related and another 1,948 stroke- related deaths in 2004 alone. US Stroke Mortality Rates (1991-1998, Adults Age 35 Years and Older) by County (Source: www.cdc.gov)
  80. 80. Acute Stroke Therapy - Thrombolysis • IV t-PA is the only FDA approved Acute Stroke Therapy when given within 3-hours of on-set.
  81. 81. Acute Stroke Therapy • IV t-PA – Improves Outcomes – Reduces overall costs to the US health system • Drawbacks – Narrow window of opportunity (3 hours) – Small risk of intracerebral hemorrhage – No access to around the clock neurologist skilled at treating stroke – Many non-neurologist reluctant to administer IV t-PA • Unfamiliar/uncomfortable with using the drug
  82. 82. Acute Stroke Therapy • 20 to 25% of stroke patients arrive to ED within 3 hours • IV t-PA is underused: Administered to only 3 to 8.5% of patients with stroke – If utilization rates increase to 20%, estimate of cost savings during first year = $429 million (currently $43 million)
  83. 83. Stroke Assistance through Virtual Emergency Support What is Arkansas SAVES? Arkansas SAVES SAVES
  84. 84. Arkansas SAVES: Purpose• Increasing subspecialty access to AR stroke patients • Impact stroke-related disability and mortality, and • Enhancing emergent stroke support by consulting on the administration of t-PA medication to eligible patients.
  85. 85. Arkansas SAVES: Rationale• Hospitals without the support of a neurologist often forgo administration of t-PA. • The time needed to affectively administer t-PA is often lost when transporting patients. • Arkansas’ stroke patients are missing out on this quality-of-life-saving drug.
  86. 86. Tele-Stroke Pool of neurologists
  87. 87. Pilot Hospitals • Spoke Hospitals – Mena Regional Health System – Booneville Community Hospital – Johnson Regional Medical Center (Clarksville) • Additional 6 hospitals to join in year 1. • Hub Hospitals – University of Arkansas for Medical Sciences – Sparks Health System (Ft. Smith)
  88. 88. EMS or triage nurse identifies acute stroke victim and notifies local ER physician ER physician confirms acute stroke (history and exam) ECG, Labs, CT scan Ischemic Stroke Telestroke system activated; on-line connection leading to 2-way viewing between patient, local physician, patient’s family, and stroke neurologist at remote site -Risk/benefits discussed; CT/Labs reviewed -IV t-PA given if appropriate. Other aspects of acute management decided -Monitored care plan set-up -Patient treated locally. Can be transferred if needed Other Tumor ICH SAH Large ICH Request for transfer Case reviewed (history, exam, CT, Labs) Given poor condition and prognosis, ER physician and family advised against transfer Transfer Acute Stroke Therapy – Telestroke Scenario
  89. 89. Arkansas SAVES: Hope for AR

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