Stewart ferguson afhcan

Alaska Native Tribal Health Consortium 1

The AFHCAN Telehealth ProgramStewart Ferguson, PhD

Chief Information Officer (CIO)Alaska Native Tribal Health Consortium

Context The Role of Telemedicine Impact of Telemedicine Financial Model for Telemedicine The Future


ALASKA

• 47th in road miles– 75% Alaskan communities unconnected by

a road to a hospital. – 25 of these have no airport.

• Population density is 1.1 persons/mile2

– 70 times smaller than the national average.

National Travel and Safety Board (NTSB) reported 436 commuter aircraft accidents in Alaska from1990-2004 (2.8 accidents a month) - accounting for 36% of all commuter aircraft accidents in the US.

• 1st in land mass– 1,420 miles (N-S)– 2,400 miles (E-W)

• 33,900 miles of shoreline– More than all of the contiguous

states combined.


ALASKA’s PHYSICIANS

• 49% of all physicians in Alaska are primary care physicians (2002 data). U.S. average is 28%

• Alaska is 48th in “doctors to residents” ratio– 65% are located in Anchorage– Shortages in many specialties– 579 Community Health Aides in 200 villages provide nearly ½ million

encounters each year.AI/AN U.S. Gap

MD 73.9 220.6 66% Lower

DD 24.0 61.8 61% Lower

Nurse 229.0 849.9 73% Lower

DISPARITIES:Health Staff per 100,000 people


Point Hope

Kotzebue

Anchorage

Rural residents travel an average of 147 miles one wayfor access to next level of care.

Ann ArborChicago

Washington DC


CONTEXT

ALASKA NATIVES ARE THE HEALTHIEST PEOPLE IN THE WORLDANTHC VISION

Alaska Native Tribal Health Consortium

Years of Potential Life Lost, Alaska Natives, 2004-08

0 5000 10000 15000 20000

Diabetes (n=39)

COPD (n=96)

Pneumonia/Influenza (n=35)

Cerebrovascular Disease (n=70)

Homicide (n=56)

Chronic Liver Disease (n=114)

Heart Disease (n=328)

Cancer (n=555)

Suicide (n=250)

Unintentional Injury (n=451)

n=number of deaths before age 75 years

Source: Alaska Epidemiology Center, ANTHC; Alaska Bureau of Vital Statistic


Historically, Alaska Native and Canadian First Nations populations have been burdened with a high prevalence of otitis media and associated morbidity.

The incidence of ambulatory care visits related to otitis media for American Indian and Alaska Native children is twice that for all U.S. infants.

The placement rate for tympanostomy tubes in these children less than age five was 20 times higher in Alaska compared to the continental U.S.


Alaska Tribal Health System

• The Indian Health Service funds only about 65% of the level of need.

• The tribal organizations must fund-raise to obtain sufficient funds to provide quality care. – Uncompensated care impacts the ability of these

health care systems to provide care to their beneficiaries as well as others.


• Ear Disease– Audiometer, Tympanometer, Video

Otoscope• Heart Disease

– ECG & Vital Signs Monitor• Respiratory Illness

– Spirometer & Vital Signs Monitor• Trauma, Skin & Wound

– Digital Camera• Dental Problems

– Dental Camera• General

– Scanner & Forms

Designing A Primary Care Tool

10


A User Interface Designed by Users

11


AFHCAN Telehealth Program Managed by ANTHC Federally funded 28 Staff 11 year Operational History

33,000 cases/year131,628 Cases (ATHS)

Installed Customer base includes: Alaska: 248 sites, 44 organizations

59 operational systems in 20111,443 providers in 201122,763 patients in 2011 (16% of AN pop)

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


THE ROLE OF TELEMEDICINE


We only assume patients travel to nearest region


Role of Telemedicine

• S&F– 3% of encounters– Primary Care (75%)– Specialty Care (25%)– Triage / Planning– Discharge Planning– Esoteric : Abuse …

– Teleradiology– Telepharmacy

• VtC– Cardiology– Liver/Hepatitis– Pediatrics– Breast Cancer

Screening– Mental Health / API

• RPM

AudiologyCardiologyCare Coordination CenterDentalDermatologyEmergency DepartmentEndocrinologyFamily MedicineGastroenterologyHISInternal MedicineNeurosurgeryOpthalmologyOrthopedicsOtolaryngologyPediatrics-OutpatientPodiatryPulmonologyRheumatologySurgeryUrologyWomen’s Health


By the numbers …

16ATHS (Alaska Tribal Health System) (1/1/2001 to 3/31/2012)

131,62865,314

2,9681,854

Cases created

Patients served

Providers involved

Providers creating


IMPACT OF TELEMEDICINE


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 do Telemedicine?

• Best for patient care• Increased access for 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


Deployment of the IHS-JVN in Alaska using a portable platform reversed a seven year decline in rates for the state

Joslin Vision Network (JVN)Portable JVN Pilot

20002001

20022003

20042005

20062007

20082009

0%

10%

20%

30%

40%

50%

60%

70%

DR

Exam

Rat

e

15% Increase

25% Decrease Portable JVN implemented


Pre-Operative Planning for Ear Surgery Using Store-and-Forward TelemedicineJohn Kokesh M.D., A. Stewart Ferguson Ph.D., Chris Patricoski M.D.

Comparison of surgical time (actual surgical time – estimated surgical time) for telehealth and non-telehealth cases. Values in the right half of the plot represent cases which took longer than planned (42% of telehealth cases and 47% of non-telehealth cases); values in the left half represent cases that took less time than planned (58% of telehealth cases and 53% of non-telehealth cases)

0%

5%

10%

15%

20%

25%

30%

35%

40%

-3 -2.5 -2 -1.5 -1 -0.5 0.5 1 1.5 2 2.5 3

Perc

ent o

f Pati

ents

Actual Surgical Time - Planned Surgical Time (hrs)

NonTelemed

Telemed

The average difference was not statistically different between the two groups: 32 minutes for the telemedicine evaluation group and 35 minutes for the in-person evaluation group


$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


Speed of Reply

91%

73%

59%

43%

28%

0%

20%

40%

60%

80%

100%

% C

ases

Turnaround Time

1 Day Same Day 4 Hour 2 Hour 1 Hour


How important is the speed of reply?(% “Extremely Important)

• Speed of response is clearly more important to Initiators compared to Consultant

• High User Initiators - 43% rated this 5 out of 5 (“Extremely Important”)

24

High Use

r (Initiator)

High Use

r (Consu

ltant)

Medium U

ser (

Initiator)

Medium U

ser (

Consulta

nt)

Low U

ser (

Initiator)

Low U

ser (

Consulta

nt)0%5%

10%15%20%25%30%35%40%45%50%

When using AFHCAN for patient care – how important is the speed of reply of the consulting doctor?


THE FINANCIAL MODEL FOR TELEHEALTH


Medicaid-Eligible Patients

A total of 5,925 telehealth specialty consults with provided to 3,663 unique patients.

$0

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

$70,000

2003 2004 2005 2006 2007 2008 2009

Medicaid PaymentsMedicaid payments totaled $269,893 to ANMC for specialty telehealth consults.


We only assume patients travel to nearest region


Medicaid Study: 2003-2009Decreased Travel = Cost Savings

Quantity Cost

Claims Paid by Medicaid 4,482 ($269,894)

Telemedicine Prevented TravelNotes:• Travel is saved for 75% of all patients. • Assume all patients under 18 need an escort• Travel costs based on 1 week advance fares

3,662 $3,116,034

Net Savings Realized by Medicaid $2,846,140

Note: For every $1 spent by Medicaid on reimbursement, $10.54 is saved on travel costs.

Outreach clinics saved another $3.4m in travel costs


In FY11, 301 pediatric patients were transported from the YKHC by LifeMed at a cost to Medicaid of $2.86 million

Average cost: $9494 per patient

Telehealth may prevent 20% of such transports


In FY11, the total amount spent on non-emergent medical travel and accommodation for all IHS patients in Alaska was $38.6 million

Patients aged 0-18 years accounted for 53.7% of all travel & accommodation costs statewide


THE FUTURE


The New Limiting Step


Growing Usage

33

0%

10%

20%

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90%

100%

1 2 3 4 5 6 7 8 9 10

High & Medium Users (11 YR) n=14




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1 2 3 4 5 6 7 8 9 10






0500

1,0001,5002,0002,5003,0003,5004,000

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012(Proj)

Case

s Cre

ated

Cases Created per Year• Good will and

commitment• Earned time off for

volume done• Provider time allocated

to telemedicine• Financial incentive to

do the “additional” work

Improve Performance with Scale

0.0

0.5

1.0

1.5

2.0

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3.0

3.5

2010 Q4 2011 Q1 2011 Q2 2011 Q3 2011 Q4 2012 Q1

Med

ian

Turn

arou

nd T

ime

(Hrs

)

Median Turnaround Time (hrs)


The Commoditization of Telehealth

• Telehealth will part of a blended health visualization– Video, Audio, Health Record, Images, Devices

• Lightweight commodity platforms– Portable, direct to desktop– Integrated into local EHR– HTM will evolve to smart systems, full integrated

• Leverage large scale infrastructures e.g. MPI

Technology is a STRATEGY to

improve performanceand to manage

costs & risk


Pay for Value

• Simplified Fee Structures– Existing coding poor match

• Business models will move well past “fee for service” concepts - eVisits, employee plans, systemic approaches.

• Fee for Service will not be as relevant. Bundled case management plans and other plans make more sense.


Drivers for Different Business Models

• Telehealth is only a financially viable solution at scale• Scale is HARD.

– Few models for maximizing performance at scale– May drive Buy versus Build outsourced care

• Need risk avoidance models e.g. ACO, HMO• Demand will continue to outstrip resources

– Non traditional usage models for efficiency gains– Innovative pilot models needed – opportunity exists

• Market differentiator – Empower consumers• Need business models NOT based on reimbursement


[email protected]

Stewart ferguson afhcan

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