Telemedicine Standards in DoD  NIST 13 December 2006 Hon S. Pak, LTC MC USA TATRC-MRMC
AKO Teleconsultation Summary <ul><li>Program Summary </li></ul><ul><ul><li>10+ specialties with contact groups:  [email_ad...
AKO.Consult Program Summary <ul><ul><li>[email_address]   </li></ul></ul><ul><ul><ul><li>Managed by the Institute for Surg...
Program Summary by:   Specialty Location Patient Branch 63% Iraq 11% Afghanistan 8% Kuwait 56% Army 12% Local National 9% ...
Teleconsultation is routed to the appropriate specialty group Consultant emails recommendation to the deployed physician O...
Army Medical Department  Policy for use of E-mail Tele-consultation  for Deployed Providers
Teleconsultation Standards <ul><li>Policy/Standards </li></ul><ul><ul><li>Clinical  </li></ul></ul><ul><ul><ul><li>Guideli...
Western Ft. Irwin Ft. Lewis (MAMC) Ft.  Wainwright Pacific Tripler (TAMC) 121st  General  Hospital GE PACS Ft. Monmouth Ft...
Tele-Health Initiatives    Tele-Echocardiology <ul><li>Availability of echo depends on access to sonographer, equipment an...
Telehealth Initiatives  Tele-Dermatology <ul><li>17,805 consultations since inception of program </li></ul><ul><li>18 repo...
Other Applications <ul><li>Teleneurosurgery </li></ul><ul><li>Telemental health </li></ul><ul><li>E-ICU </li></ul><ul><li>...
Observations <ul><li>No enterprise Telemedicine programs other than teleradiology </li></ul><ul><ul><li>Except Telemedicin...
Need for Better Standards <ul><li>DoD Telemedicine </li></ul><ul><ul><li>Standards localized to regional programs not a ce...
DoD Telemedicine Challenges <ul><li>Lack of Technical Standards to adopt </li></ul><ul><ul><li>Few exceptions (Diabetic re...
Future <ul><li>Assumption: Convergence of Telemedicine with Health Information Technology (HIT)  </li></ul><ul><li>Standar...
Recommendations <ul><li>ATA and NIST must take leadership in development of  </li></ul><ul><ul><li>An overarching telemedi...
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Telemedicine Standards in DoD NIST

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  • The Army PACS world is carved up into various vendor PACS and Teleradiology Products as depicted in the slide. Our Global Teleradiology Program is implemented on top of PACS to provide secure transmission and access to Teleradiology exams anywhere needed. We are using the Medweb product for this, and the Navy and Air Force have adopted this product as well for their new telerad sites. TATRC is working to get other telemedicine applications ported over to this same platform, e.g. TeleDerm, Path, Ocular, and other; - preserves the principle of “conservation of boxes” and simplifies operation and support
  • Remote interpretation of echo cardiology exams began in November 1997 between Fort Sill and BAMC using a VHS video tape mailed from Sill to the cardiologists at BAMC for interpretation and was expanded to Fort Polk in Mar 1998. In 2002, the cardiology system at BAMC was upgraded to a digital system allowing the elimination of video tapes and a transition to exam movement through the network with further expansion of the program to Fort Hood, Fort Carson and Fort Leonard Wood. For echocardiology, a site must have an echocardiograph and a sonographer and access to a cardiologist. In Tele-echocardiology, the access to the cardiologist is provided by digitally moving the exam to BAMC who has a contract cardiologist interpret the exam at a cost of $65 per exam. This compares to a cost of $600 to $1000 if that patient is referred to a network cardiologist. In calendar year 2002, BAMC interpreted 997 exams at a cost savings of between 500,000 and 1,000,000 dollars. BAMC’s Health Plan Management is working a business case analysis to fund the contract exam interpretation cost for FY 04.
  • The military has lost 50% of their dermatology physicians in the last ten years and the forecast is we will continue to lose dermatologists. Teledermatology can be used to overcome this loss. The patient benefits the most from improved access and higher level of care. In many of our remote MTFs the waiting time to access a network dermatologist approaches three months. The primary care providers are empowered with dermatological knowledge and are able to provide a better quality of care for future patients with dermatology problems through participation in T-Derm. The AMEDD benefits by being able to more efficiently utilize our limited dermatology resources and reduce overall healthcare costs. Teledermatology is clinically effective which, is backed by published peer reviewed studies. Close to 90% of all dermatological conditions can be managed via teledermatology. Today, there is no financial incentive for an MTF to spend their limited resources to recapture dermatology workload currently being sent to the network. However, when TNEX goes into effect, MTF’s will have an incentive to recapture using teledermatology. Our program is focused on revising the business process to maximize the utilization of teledermatology by having a consult manager review consult requests and capture referrals for dermatology prior to them being appointed to see dermatologist or sent to the network. At our test site, Fort Hood, we provided a dedicated resource to the MTF to take the images and manage the program. This enabled us to change the business process to allow teledermatology to be integrated into the existing consult flow with outstanding results as shown in the graph in the lower right corner. Since Teledermatology began at Hood in Feb 02, the number of purchased care claims decreased by 79% when you compare Feb 02 to Sep 02. This downward trend has continued through the first five months of FY03. In short, the new business process minimally changes the normal workflow of the primary care provider. We have submitted a venture capital business case analysis to expand the Fort Hood model to other MTFs in the Region (FY 04 cost is $769K). Teledermatology began in Feb 2002; with a focus of supporting sites without a dermatologist or those not meeting access standards for dermatology care. All images are captured at the site and sent to the telederm server at GPRMC. The dermatologist responsible for interpreting the images logs on to the web server and answers the consult request (the 3 sites listed rotate responsibility for interpretation). There is a great potential for recapturing referrals from the network.  
  • Telemedicine Standards in DoD NIST

    1. 1. Telemedicine Standards in DoD NIST 13 December 2006 Hon S. Pak, LTC MC USA TATRC-MRMC
    2. 2. AKO Teleconsultation Summary <ul><li>Program Summary </li></ul><ul><ul><li>10+ specialties with contact groups: [email_address] </li></ul></ul><ul><ul><li>1,886 teleconsultations (April 2004 to July 2006 – 29 months) </li></ul></ul><ul><ul><li>47 known evacuations prevented </li></ul></ul><ul><ul><ul><li>3 evacuations prevented in August </li></ul></ul></ul><ul><ul><li>42 known evacuations facilitated following consultant’s recommendation </li></ul></ul><ul><ul><ul><li>5 evacuations facilitated in August </li></ul></ul></ul><ul><ul><li>648 different referring health care professionals </li></ul></ul><ul><ul><li>250 teleconsultations on non - US patients </li></ul></ul><ul><ul><li>Average Reply Time 5 hr 9 min </li></ul></ul>
    3. 3. AKO.Consult Program Summary <ul><ul><li>[email_address] </li></ul></ul><ul><ul><ul><li>Managed by the Institute for Surgical Research, Ft Sam Houston </li></ul></ul></ul><ul><ul><li>[email_address] </li></ul></ul><ul><ul><ul><li>Managed by BAMC Cardiology </li></ul></ul></ul><ul><ul><li>[email_address] </li></ul></ul><ul><ul><ul><li>4 Call Teams: BAMC, Walter Reed, Western, and Atlantic </li></ul></ul></ul><ul><ul><li>[email_address] </li></ul></ul><ul><ul><ul><li>On-call ophthalmologists based in Germany and Eastern US </li></ul></ul></ul><ul><ul><li>[email_address] (Infectous Diseases) </li></ul></ul><ul><ul><ul><li>3 Call Teams: BAMC, Walter Reed, and Western </li></ul></ul></ul><ul><ul><li>[email_address] </li></ul></ul><ul><ul><ul><li>Managed by various Army, Navy, and Air Force call teams </li></ul></ul></ul><ul><ul><li>[email_address] (Pediatrics Intensive Care) </li></ul></ul><ul><ul><ul><li>Walter Reed based with call teams from Hawaii to Germany </li></ul></ul></ul><ul><ul><li>[email_address] </li></ul></ul><ul><ul><ul><li>Preventive Medicine and Occupational Medicine … managed by CHPPM </li></ul></ul></ul><ul><ul><li>[email_address] </li></ul></ul><ul><ul><ul><li>BAMC based with participation by all DoD toxicologists </li></ul></ul></ul><ul><ul><li>[email_address] </li></ul></ul><ul><ul><ul><li>Managed by TAMC with participation from many MTFs </li></ul></ul></ul>
    4. 4. Program Summary by: Specialty Location Patient Branch 63% Iraq 11% Afghanistan 8% Kuwait 56% Army 12% Local National 9% Marine Corps 73% Dermatology 10% Infectious Dz. 5% Ophthalmology
    5. 5. Teleconsultation is routed to the appropriate specialty group Consultant emails recommendation to the deployed physician On-Call consultant retrieves and reviews teleconsultation Copy furnished to specialty group…confirms teleconsultation is answered and enables collaboration Teleconsultation Program Business Practice Deployed Provider emails consultation
    6. 6. Army Medical Department Policy for use of E-mail Tele-consultation for Deployed Providers
    7. 7. Teleconsultation Standards <ul><li>Policy/Standards </li></ul><ul><ul><li>Clinical </li></ul></ul><ul><ul><ul><li>Guideline for what is and is not appropriate </li></ul></ul></ul><ul><ul><ul><li>What information to include </li></ul></ul></ul><ul><ul><ul><li>Imaging Protocol </li></ul></ul></ul><ul><ul><li>Administrative </li></ul></ul><ul><ul><ul><li>Guideline for training </li></ul></ul></ul><ul><ul><ul><li>Process and procedures to include QA </li></ul></ul></ul><ul><ul><ul><li>Time Standard for answering consults </li></ul></ul></ul><ul><ul><li>Technical (weakest) </li></ul></ul><ul><ul><ul><li>1024x768 resolution recommended… </li></ul></ul></ul><ul><ul><ul><li>Problem: No standardized digital camera </li></ul></ul></ul>
    8. 8. Western Ft. Irwin Ft. Lewis (MAMC) Ft. Wainwright Pacific Tripler (TAMC) 121st General Hospital GE PACS Ft. Monmouth Ft. Sill Ft. Drum West Point Ft. Carson Ft. Huachuca Ft. Hood Ft. Sam Houston (BAMC) Ft. Polk Ft. Knox WRAMC Ft. Leonard Wood Ft. Riley Ft. Leavenworth Ft. Eustis Ft. Lee Ft. Meade Ft. Belvoir WBAMC North Atlantic Great Plains Ft. Bragg Redstone Arsenal Landstuhl Heidelberg Wuerzberg Siemens PACS Europ e Ft. Jackson Ft. Campbell Ft. Stewart Ft. Gordon (DDEAMC) Ft. Rucker Ft. Benning Ft. McClellan Digital Radiology– Where are we today? Agfa PACS IBM PACS Southeast Ft Buchanan, PR JTF Bravo
    9. 9. Tele-Health Initiatives Tele-Echocardiology <ul><li>Availability of echo depends on access to sonographer, equipment and cardiologist </li></ul><ul><li>Digital echo and telemedicine technology bridge the gap to specialty diagnostic imaging </li></ul><ul><li>All echos are read at BAMC </li></ul>
    10. 10. Telehealth Initiatives Tele-Dermatology <ul><li>17,805 consultations since inception of program </li></ul><ul><li>18 reporting facilities </li></ul><ul><ul><li>188 Army consults or 62% of total </li></ul></ul><ul><ul><li>92 Air Force consults or 30% of total </li></ul></ul><ul><ul><li>23 Navy consults or 7% of total </li></ul></ul>Army Site Air Force Site Navy Site GITMO
    11. 11. Other Applications <ul><li>Teleneurosurgery </li></ul><ul><li>Telemental health </li></ul><ul><li>E-ICU </li></ul><ul><li>Others </li></ul>
    12. 12. Observations <ul><li>No enterprise Telemedicine programs other than teleradiology </li></ul><ul><ul><li>Except Telemedicine for Deployed Environment </li></ul></ul><ul><li>Regional Centers of Excellence </li></ul><ul><ul><li>GPRMC (Teledermatology, Tele-echo) </li></ul></ul><ul><ul><li>WRAMC (Telemental Health) </li></ul></ul><ul><ul><li>Tripler (e-ICU) </li></ul></ul>
    13. 13. Need for Better Standards <ul><li>DoD Telemedicine </li></ul><ul><ul><li>Standards localized to regional programs not a centralized program </li></ul></ul><ul><ul><li>Army has the only Policy/Standards in telemedicine </li></ul></ul><ul><ul><ul><li>Administrative </li></ul></ul></ul><ul><ul><ul><li>Clinical </li></ul></ul></ul><ul><li>Issues </li></ul><ul><ul><li>Lacking in technical standards </li></ul></ul><ul><ul><li>Lack of standardized equipment </li></ul></ul><ul><ul><li>Training variability from region to region </li></ul></ul><ul><ul><li>Pressure to create DoD wide standardized policy lacking… since telemedicine still region based… </li></ul></ul>
    14. 14. DoD Telemedicine Challenges <ul><li>Lack of Technical Standards to adopt </li></ul><ul><ul><li>Few exceptions (Diabetic retinopathy) </li></ul></ul><ul><li>Lack of Process & Framework to develop new telemedicine standards </li></ul><ul><li>Lack of Standards has created </li></ul><ul><ul><li>Limited telemedicine technology availability </li></ul></ul><ul><ul><li>Training has been difficult (digital camera) </li></ul></ul>
    15. 15. Future <ul><li>Assumption: Convergence of Telemedicine with Health Information Technology (HIT) </li></ul><ul><li>Standards should not be developed in isolation but rather in close coordination with other organizations developing standards </li></ul><ul><li>Trends in HIT </li></ul><ul><ul><li>Image Standards (DICOM) </li></ul></ul><ul><ul><li>CDA-R2 </li></ul></ul><ul><li>Partnerships </li></ul><ul><ul><li>Office of National Coordinator </li></ul></ul><ul><ul><li>NIST </li></ul></ul><ul><ul><li>Industry </li></ul></ul><ul><ul><li>Specialty Physician, Nursing, Other Healthcare Organizations </li></ul></ul><ul><li>ATA needs to take the leadership role in telemedicine standards… </li></ul>
    16. 16. Recommendations <ul><li>ATA and NIST must take leadership in development of </li></ul><ul><ul><li>An overarching telemedicine standards </li></ul></ul><ul><ul><li>Framework for specialty specific standards </li></ul></ul><ul><ul><li>Home health care explosion </li></ul></ul><ul><li>Partnership is Key </li></ul><ul><ul><li>Vendor </li></ul></ul><ul><ul><ul><li>More standardized telemedicine equipment </li></ul></ul></ul><ul><ul><ul><li>Lower cost in equipment and training </li></ul></ul></ul><ul><ul><li>ONC </li></ul></ul><ul><ul><li>Technical Standards Organization: ISO/HL-7/DICOM,Others </li></ul></ul><ul><ul><li>Specialty Societies </li></ul></ul><ul><li>Focus </li></ul><ul><ul><li>Patient Safety and Quality of Care </li></ul></ul>

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