Post on 19-Nov-2014
description
Telehealth Use for Hepatitis C and HIVTelemed Experiences from Alaska
Brenna Simons,PhDLisa Townshend, ANP
Alaska Native Tribal Health Consortium
Patient Care in Alaska:Many Challenges
From the Village Clinic….
…to the Regional Health Center…
…to the Central Hospital
Savoonga to Anchorage$1000
Nuiqsut to Anchorage$1100
Chevak to Anchorage$950
Old Harbor to Anchorage$1350
Point Hope to Anchorage$980
So, what is telehealth?
State of Alaska Health and Social Services, Division of Public Healthwww.hss.state.ak.us/dph/healthplanning/telehealth
Telehealth can be used to bridge gaps in specialty care
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Telehealth in Alaska Tribal Health System
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11 year Operational History33,000 cases/year125,482 Cases
(ATHS)
Installed Customer base includes: Alaska: 248 sites, 44
organizations59 operational systems in 20111,443 providers in 201122,763 patients in 2011
Other states and countries
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Case
s Cre
ated
Cases Created per Year
Telehealth Terminology
Live-interactiveRefers to telemedicine encounters where the patient, primary care
provider with the patient, and the specialist in a different location are on-line at the same time, interacting real-time and not delayed.
Store-and-forwardIn contrast to live-interactive telemedicine encounters, this means the
health provider where the patient is at stores the data from the encounter in a digital format, and then forwards the data to a specialist.
Health Information ExchangeThe coordination of appropriate electronic records for the health
needs of the patients and providers. Security is governed by patient and facility permission levels.
State of Alaska Health and Social Services, Division of Public Healthwww.hss.state.ak.us/dph/healthplanning/telehealth
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Store & Forward vs Real-Time TelehealthStore & Forward
• Asynchronous Interaction
• Documents & Images• Electronic Medical
Records• Patient Education
• Radiology• Dermatology• Pathology• Oncology• Ophthalmology• Dental
• Cardiology• ENT• GI• Pulmonary• Rheumatology
• Psychology/ Psychiatry• Neurology• Speech therapy• Physical therapy
Clinical specialties for telemedicine
• Face-to-Face Interaction
• Immediate Feedback
Remoteconsultation
Real-Time (VtC)
Ear Disease Audiometer, Tympanometer,
Video OtoscopeHeart Disease
ECG & Vital Signs MonitorRespiratory Illness
Spirometer & Vital Signs Monitor
Trauma, Skin & Wound Digital Camera
Dental Problems Dental Camera
General Scanner & Forms
Store and Forward Telemedicine
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Case originated…
…Case received.
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 efficient
Gives me confidence in doing the right thing for the patient
Increase access to care
0% 10% 20% 30% 40% 50% 60% 70%
Why Do You Use Telemedicine?
Best for patient care Increased access for care
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Outcomes
18ATHS (Alaska Tribal Health System) (1/1/2001 to 12/31/2011)
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Case
s Cre
ated
Cases Created per Year (by Role)
Primary Care Specialty Care
Telehealth Impact on Extended Waiting Times (> 4 months)
Data courtesy of Phil Hofstetter
47%
8%
3%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Pre-Telemed1991-2001(n=1216)
With Telemed
2002-2004(n=276)
With Telemed
2005-2007(n=210)
Perc
ent A
ppoi
ntm
ent A
vaila
bilit
y W
ith
5 M
onth
or L
onge
r Wai
t Tim
e
19
20
$0
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
$6,000,000
$7,000,000
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Annual Travel Savings (by Case Role)
Primary Care Specialty Care
How We Use Telehealth for Hepatitis C/HIV
Goals
Provide consultation to rural providers in Alaska
Promote education about liver disease
CEUs/CMEs
Case study format
Relaxed setting for asking questions
ANTHC Liver Disease & Hepatitis Staff
2 Physician Liver Specialists
1 Nurse Practitioner
1 Microbiologist
5 Nurses
1 Information Technologist
3 Administrative/ Support Staff
Early LiverConnect Meeting
How does LiverConnect Work?
Case Created by
Rural Provider LiverConnect Staff
NotifiedOf Case
PowerpointSlides
CreatedAboutCase
LiverConnectVideoconference
Rural ProviderPresents Case &
Liver Clinic ProvidersDiscuss Case.
plusLiver Disease or
Related TopicPresentation
LiverConnect Treatment
Recommendations Made by ANTHC
Liver Disease Providersvia AFHCAN
Copy of Relevant Notes,
Labs/Tests Scanned to
AFHCAN
Follow UpPatient Form
Completedfor Future
LiverConnect
Case Types Presented at LiverConnect
Elevated LFTsAutoimmune HepatitisHepatitis C TreatmentHepatitis B TreatmentHepatocellular CarcinomaLiver TransplantAlcohol HepatitisHepatitis C and HIV CoinfectionPatient with Liver Disease in Jail
Didactic Presentations Given at LiverConnect
Liver Disease Topics Elevated LFTs Hepatitis B Hepatitis C Autoimmune Hepatitis NAFLD Alcohol Hepatitis Statins and Liver
Disease Liver Transplantation Hepatocellular
Carcinoma
Related Topics HIV Updates Elevated LFTs and HIV Depression Rheumatologic
Manifestations of HCV Motivating Patients
with SA and Liver Disease
Adverse Childhood Experiences Study
Suicide Prevention
Distance Participants
Local Participants at LiverConnect
Using AdobeConnect for Videoconferencing
Recent LiverConnect Case Study
34 y.o. Alaska Native female
Presents with nausea/vomiting
Icterus
Afebrile
No abdominal pain
Initial Labs 10/1/11 Initial Labs 10/1/11
ALT 1166 ANA Negative
AST 896 Actin Antibody 189
Alkaline phos 226 IgG 2320
Total bilirubin 7.43 IgM 222
Hemoglobin 12.2 Hepatitis A IgM Negative
Hematocrit 37.7 Hepatitis A Ab Total Reactive/Positive
WBCs 6.5 Hepatitis B Core IgM
Negative
Platelets 347 Hepatitis B Surface Ag
Negative
Prothrombin Time
12.9/Inr <1
CMV Negative
PTT 36.1 Monospot Negative
Case YK-8 Labs
Case YK-8 Provider Questions
What’s the differential diagnosis?What other labs/tests are needed?Does patient need liver biopsy?
Case YK-8 Diagnosis - AIH
ANA negative, Actin antibody positive, IgG elevated
Liver Biopsy: AIH with marked activity and early bridging fibrosis.
Initial Treatment: Methylprednisolone 32mg and
Azathioprine 25mg.
Case YK-8 Follow Up Feb 2012
Current labs:
ALT: 36, AST: 32,
WBCs: 9.5, ANC: 7.5,
Hemoglobin: 10.5, Platelet Count: 425
Vitamin D 25OH Total: 10DEXA Scan: OsteopeniaAIH Medications: Azathioprine 75mg p.o.
daily and Methylprednisolone 7mg p.o. daily
Case YK-8 Follow Up Provider Questions
What should I be concerned about?
What tests should I order on her and when?
How long should she stay on azathioprine and methylprednisolone?
Contact Information
Past LiverConnect Presentations Viewable at ANTHC Liver Disease & Hepatitis website:
http://www.anthctoday.org/community/hep/liverconnect.html
How Telehealth Can Be Used in HCV and HIV Care
Training Providers, Nurses, Health Aides Disease Management Updates Treatment Updates Comorbid Diseases
Case Management Consultation for Difficult Cases Interactions Among Teams for Coordinated Care Direct Patient Interactions
Check-in Reiterate education given Value of seeing patient face-to-face
• Getting Started• What do you want to
accomplish?• What do you need to do this?• What works best?• Technology options
Telehealth In Your Community
Establishing a Local Telehealth Program
Technology Requirements
Legal Requirements
Handling Protected Health Information
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Feedback Mechanism
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Kirt J BeckTTAC Directorkjbeck@TelehealthTAC.org Main: 907.729.4703www.telehealthtac.org
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Creating better-informed consumers of telehealth technology.
AFHCAN offers a variety of training and educational opportunities Train the Trainer Super User 3-day Telehealth Technical Support Videoconferencing user training
E-learning options: Videoconferencing (VTC) Webinar AFHCAN computer-based training (CBT)
AFHCAN Training Options
• AFHCAN & University of Alaska offer three college courses in telehealth– Course 1- Telehealth Fundamentals– Course 2 – Beyond the Basics of Telehealth– Course 3 – Telehealth Program Management
• Completion of Courses 1&2 -certification as Telehealth Coordinator
• Completion of all 3 courses -certification as Telehealth Program Manager
• More information at www.afhcan.org
University of Alaska College Courses
Thank You!