The Challenges of an Integrated Telehealth Care Delivery...

Global Telehealth Conference 2012

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Alaska Native Tribal Health Consortium

The Challenges of an IntegratedTelehealth Care Delivery System

Stewart Ferguson, PhDChief Information Officer (CIO)


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ProjectProgramTelehealth SystemIntegrated Care Delivery System

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Alaska Native Tribal Health Consortium 6

ALASKA

• 1st U.S. State 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.

• 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.


The Doctors are NOT where the Patients ARE

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

• 59% of the state’s residents are in medically underserved areas.

• 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.

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Medical Care Service Levels

• Alaska Native Medical Center tertiary care– Referrals to private medical providers and other states for complex care

• 6 regional hospitals• 4 multi‐physician health centers• 25 subregional mid‐level care centers• 180 small community primary care centers


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Village‐Based Medical Services• 180 Small Village Health

Centers– ~550 Community Health

Aides/Practitioners– ~125 Behavioral Health

Aides– ~20 Dental Health Aides/ 12

Therapists– ~100 Home health/personal

care attendants

• Average Alaska village: 350 residents

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Savoonga to Anchorage$1000

Nuiqsut to Anchorage$1100

Chevak to Anchorage$950

Old Harbor to Anchorage$1350

Point Hope to Anchorage$980


Where we came from …


Alaska’s Experience

Barrow ‐ early 80’s

NSHC ‐ CHAIN (Community Health Aide Information Network)

Public Health Nursing

Barrow ‐ (AuroraNet Distance Delivery Health Care Project) ‐ Installed in 6 village clinics, 1 regional hospital.

“NLM Project” ‐ (ATTP ‐ Alaska Telemedicine Testbed Project) ‐ Installed in 26 village clinics, 4 regional hospitals. Over 3,000 consults in 2 years. (1997 – 1999)Funded by the National Library of Medicine (NLM Contract No. N01‐LM‐6‐3540).

AFHCAN ‐ Begin installation 9/2000. 248 sites, 43 organizations. Funded by the Veterans Administration, Indian Health Service, DHHS, Department of Defense.


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• Funded by NLM (National Library of Medicine) Contract #N01‐LM‐6‐3540– University of Alaska Anchorage (UAA)

• Fred Pearce, Ph.D. Principal Investigator

• 4 Regional Health Corporations– 26 Village clinics

• Evaluate the impact of low‐bandwidth telemedicine systems on costs, professional isolation and provider/patient satisfaction

• >3,000 cases >9,000 images in 2 years

Alaska Telemedicine Testbed Project (ATTP)


Usage versus Age

Elderly health aides use the system relatively morethan younger health aides.


• It’s NOT about the technology – it’s about the value proposition.

• The value proposition is often obvious to the more experienced providers.– Older health aides saw the value – e.g. it let them convince the new doc that they really were seeing an infected ear.

The Value Proposition Relative Use of Image Hardware

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• Non‐clinical factors will often drive usage and usage patterns … perhaps more than clinical factors.– Needs assessments have limited predictability value.

• A note about evaluation – be careful!– Hawthorn effect … or top ten ways to kill telehealth usage.

More Lessons …


• Partial participation will result in less that partial results.

• We’re either all in or it’s not worth doing.– Full participation and organization support is an important step to gain desired utilization.

• Pilots may not tell you about larger systemic issues and may not be predictors of usage.

Systemic Adoption

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A formal, voluntary, inter-agency relationship between

the DoD, DoT, IHS and VA working together by the sharing of each other’s resources, talents, and

experience to improve patient care throughout the state of

Alaska

Alaska Federal Health Care Partnership

• Veterans Affairs

• DoD (Army & Air Force)

• DoT - (USCG)

• Indian Health Service (IHS):

– Alaska Native Tribal Healthcare Consortium (ANTHC)


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AFHCAN MISSIONTo improve access to health care for federal beneficiaries in Alaska through sustainable

telehealth systems

AlaskaFederalHealthCareAccessNetwork


What are your key organizational goals for telehealth applications?

• Access to care• Patient Satisfaction• Quality of Care• Information Transfer• Costs/Economics• Continuity of Care• Other

Please rank in order of importance to your organization:


What are your key organizational goals for telehealth applications?

EXECUTIVE BOARDCEO / Commanders

ANMC, VA, USCG, 3MDG, BACH, 354 MDG

STEERING BOARDAFHCP Planning Board Chairman, AFHCP Project Officer, AFHCP Business Office

Director, ANMC Data Manager, and Clinical and Tribal Representatives

ClinicalTraining

Technology

Informatics

Business

AFHCAN Project Office

AFHCANPartners


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The Alaska Telehealth Advisory Council (ATAC) was established in 1999 to provide a forum that enhances collaboration and communication between organizations involved in telehealth initiatives.

http://www.hss.state.ak.us/dph/Healthplanning/telehealth/atac/default.htm

ATAC members provide direction, leadership and coordination of telehealth efforts throughout Alaska.

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• 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


A User Interface Designed by Users

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THE ROLE OF TELEMEDICINE


AFHCAN Telehealth Program

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Managed by ANTHCFederally funded28 Staff12 year Operational History

33,000 cases/year140,000 Cases (ATHS)

Installed Customer base includes:Alaska: 248 sites, 44 organizations59 operational systems in 20111,425 providers in 201220,719 patients in 2012 (15% of AN pop)

Other states and countries


When Do You Need A Telemedicine Consultation?

• Uncertain about the diagnosis.

• Uncertain about the treatment.

• Uncertain about the outcome; complications

Specialist participation earlier rather than later: “Expert Level Triage”


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

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AudiologyCardiologyCare Coordination CenterDentalDermatologyEmergency DepartmentEndocrinologyFamily MedicineGastroenterologyHISInternal MedicineNeurosurgeryOpthalmologyOrthopedicsOtolaryngologyPediatrics‐OutpatientPodiatryPulmonologyRheumatologySurgeryUrologyWomen’s Health


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IMPACT OF TELEMEDICINE

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Improving AccessGreater Efficiency of Existing Resources


Telehealth Impact on Extended Waiting Times (> 4 months)

Data courtesy of Phil Hofstetter


Access

Data courtesy of Phil Hofstetter


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0% 10% 20% 30% 40% 50% 60%

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

Why do you do Telemedicine?

• Best for patient care• Increased access for care


Providing Care in the Patient’s Community


Patient Visits

Cost

Traveling Audiologist Program 1,987 ($175,000)

Patient Travel PreventedBased on Outcomes of:

• Did patient still need to travel to field clinic?Assumptions:

• Only travel to hub is being saved. • Escort required if patient less than 18 years old• No lodging / per diem calculated

1,726Note: 1,153

less than 18 yrs old

$697,090

Net Savings in Travel Costs Realized by Program

$522,090(300% ROI)

Extending Careto the Village


OutcomesNote1: 1,987 patients

About 72% of the patients seen needed something done (meds, surgery, ongoing monitoring) and 26% needed to be

screened out.

Note2: Percentages may not add to 100% due to multiple outcomes per case.


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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

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25% Decrease Portable JVNimplemented


Reducing Costs


Medicaid Study: 2003‐2009Decreased Travel = Cost Savings

Quantity CostClaims Paid by Medicaid 4,482 ($269,894)Telemedicine Prevented Travel

Notes:• 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

43 Alaska Native Tribal Health Consortium44ATHS (Alaska Tribal Health System) (1/1/2000 to 9/30/2012)


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Alaska Native Tribal Health Consortium45ATHS (Alaska Tribal Health System) (1/1/2000 to 9/30/2012)


Telemedicine makes my JOB MORE FUN. (n=4,787)

For this case, rate the following statement:

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Provider Feedback over Time

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Provider Feedback over Time


Hiring Providers

• Alaska rural facilities spent $12,000,000 in 2004 to recruit for 13 provider types.

• The average cost to hire a provider is $38,000.– Tribal health organizations that include hospitals in their system

expended $66,000 per new hire.– Rural health facilities average $42,575 to recruit each registered nurse

• Alaska’s rural hospitals spent approximately four times the national average to hire providers.– Clinics spent approximately seven times the national average.

• This is only magnified when considering the higher turnover rate.


Improving Processes


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Post‐Operative Followup

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• Post‐surgical follow‐up is difficult for patients from remote settings.

• Telehealth provides ability to monitor and followup.

“Many simple problems, such as tympanostomy tube follow-up can be done with telemedicine without asking the patient to leave their village.“

ENT Specialist

– Validated model– “Reverse Consult”

empowers CHA/Ps and midlevels to respond to requests from specialists.

% CONCORDANCE ON PHYSICAL EXAM

99% 99% 97% 96%99%

94%90%

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Tube In TubePatent

Drainage Perforation Granulation Middle earfluid

Retracted

Physical Exam Descriptors

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InterProvider (Exam0)

IntraProvider using all images (Exam0 vs Review1,2)

IntraProvider using "good" images (Exam0 vs Review1,2)

High level of agreement Correlation between in person exam and telemedicine exam good to excellentTelemedicine can be used to do routine ear tube follow upMake available several hundred appointments per year

Kokesh J, Ferguson AS, Patricoski C, Koller K, Zwack G, Provost E, Holck P. “Digital images for postsurgical follow-up of tympanostomy tubes in remote Alaska”. Otolaryngology-Head and Neck Surgery, 139:87-93, 2008.

Patricoski C, Kokesh J, Ferguson AS, Koller K, Zwack G, Provost E, Holck P. “A Comparison of In-Person Examination and Video Otoscope Imaging for Tympanostomy Tube Follow-Up”. Telemedicine Journal and e-Health, 9(4):331-344, 2003.


Overall Image Rating

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Very Poor Poor Adequate Good Excellent

Study #1Study #2


Nationally, hospital discharge summary is rarely available (12 ‐34%) to the physician at the first post‐discharge visit and remains poor at 4 weeks (51%‐77%).

Discharge Notes

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Kripalani S Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA - 28-FEB-2007; 297(8): 831-41.

AFHCAN was used to generate 20,000 discharge summaries in FY12, and is now being fully automated


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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)

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


Speed of Reply

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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”)

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High User (Initiator) High User (Consultant) Medium User (Initiator) Medium User (Consultant)

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


The Challenges of an IntegratedTelehealth Care Delivery System

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• Many telehealth systems have demonstrated efficacy

• The challenge is obtaining a consistent application of procedures that are known to produce results … and responding to the business in a timely manner … at volume.

The Challenge of Scale


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• Telehealth is more cost effective at higher volumes • Highly sensitive to:

– How often telehealth eliminates the need for subsequent in‐person encounter

– Originating telehealth from patient’s location

Costing Model

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Patient locationPatient ageProvider locationReimbursement ratesDenial ratesPredicted coding levelsPayer mixFacility feeTelehealth originating feeEncounter typeTravel costsLodging costsPer diem costs

Estimating the COST PER ENCOUNTER for delivering specialty care … by traditional versus telehealth modelNo Show rate

Patient lost work timeProvider lost work timeLength of encounterSupport staff costClinic space costsClinic equipment costsHardware costsSoftware costsSupport costsConnectivity costsProvider salaryTraining costs

System Variables include:


Challenge ‐ Systemic Adoption

Champion Service Model• Can

– See potential– Create– Innovate– Nurture

• Can’t– Sustain– Grow to large scale– Leave something behind

Guarantee of performance

Agreed upon expectations

Sustainable and scalable

Accountable

Independent of individuals

Requires support structure

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Service Model

• Remains even when the individuals change• Supports non‐linear growth• Requires support structure

– Training & Knowledge Management– Technical– Monitoring– Data collection– Customer service


TRAINING


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Alaska Native Tribal Health Consortium 61 Alaska Native Tribal Health Consortium

• Training is no longer seen as an instance in time event

• Workshops created to help regional trainers learn more about using the hardware and software, structuring their own training programs

• Curriculum developed by trainers, for trainers• Distance delivery and self‐paced learning via videoconferencing, Webinars, and computer‐based training

What Has Changed


• Course I: Understanding Telehealth & the Role of the Telehealth Coordinator– Topics include telehealth applications, specialty uses, rural impact,

case management, business aspects, etc.

• Course II: Becoming a Certified Telehealth Coordinator– Provides attendees the tools & skills needed to support the use of

telehealth

• Course III: Becoming a Certified Telehealth Program Manager– Provides attendees the tools & skills needed to manage telehealth

programs

Online Certification Courses


• Evolved from a training focus to a bigger picture view that incorporates program development and education– Using education as a driver for systemic change– Assisting organizations with clinical workflow design, program evaluation & adoption

– Fostering relationships between referring healthcare providers and consultants

Training Program Development


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It’s all about relationships …Almost 250 more patients are being seen per year, a savings in 80 man‐years of waiting time.

2.6 cases/month 7.9 cases/month


• Clinicians and nurses have their hands full treating patients

• One of AFHCAN’s key roles is to:– Observe what clinicians are doing and help them integrate telehealth in ways that can make them more efficient

– Get care to patients that need it, and faster– Save “someone” time & $$

• We provide this service because we have the experience and it is what we do

Program Development

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Four Star Status

Receive electronic request for consultation for the majority of patient casesSpecialty Clinics provide consultation, documenting in tConsult and sending the case back to the referral siteHave a defined process for billing for telehealth including patient registration and collaboration with coding dept. Have a defined Clinical Admin. User (staff member whose role is to manage staff user accounts and customized clinic form in tConsult)


SUPPORT


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• How we have changed– Proactive– Focus on customer and product being more self‐reliant and knowledgeable

– Provide online resources– Directly tied to quality and product development initiatives FDA medical device.

– Survey customers regarding our product and services

Customer Support


Customer Support (more)

• What has changed– Partnering to offer VTC training to shared customers

– Server support for various initiatives and programs– Consulting to organizations considering integrating telehealth with the EHR (data and visually)

– Technology assessment beyond AFHCAN centric equipment


• 10 Years Ago– “Should we do telemedicine”– “Will patients be satisfied”– “How do we do telemedicine”

• Now– “How do we integrate telehealth with the care environment”

– “How can we support and expand telehealth capability”

The questions have changed …

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Corporate Policy … would be considered in a “telemedicine” priority situation …”


“Symptoms” of an IntegratedTelehealth Care Delivery System

• Fully reimbursed• Integrated with EHR• Embedded within Strategic Health Plan

– Regular communication with payers, providers, leadership

• Supported by Corporate Policy• Challenged by scale

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The Clinician’s Perspective… the New Limiting Step


ComputersEmail

NetworksVTC

TextingIMSMS

FacetimeCellphones

EHRs

AND ALL THE OTHER STUFF

Don’t let

Prevent you from meeting, talking, arguing, understanding, sharing


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• 400 Scientific Presentations• 200,000 Square Feet of Exhibits• > 5,000 Attendees

The World's Largest Telemedicine, Telehealth & mHealth Trade Show

ATA 2013 - 18th Annual International Meeting & Trade Show

May 5-7, 2013 in Austin, TX

www.ATA2013.org

Some ATA Strategies for FY13• Work with strategic stakeholders to expand involvement and support for the public policy changes.

• Develop and distribute an evidence base and case studies for telehealth resulting in a compendium of validated scientific research on cost, quality and access.

• Drive the adoption of “best practices” in telehealth.

• Develop a comprehensive educational program that consolidates webinars, video casts, online courses and other activities of ATA and member groups with regularly scheduled events.

• Drive consumer awareness of telehealth

Practice GuidelinesCOMPLETED

Teledermatology Quick Guides for Live‐ Interactive and Store and ForwardTelepresentingDiagnosis of Diabetic RetinopathyTelerehabilitationTelemental Health – Video‐Based Evidence‐based Telemental HealthCore Standards for Telemedicine NetworksTeledermatologyHome TelehealthTelepathology

IN PROGRESS

• Remote Prescribing– Jim Greene, Peter Yellowlees

• Desktop & Internet TelementalHealth– Carolyn Turvey

• Remote Health Monitoring Data Management– Nina Antoniotti

• TeleUrgent/Primary Care– Frances Gough

• TeleICU• Telepathology

– Liron Pantanowitz• Telestroke• Teleradiology

– Elizabeth Krupinski

ATA TeleICU Guidelines Working Group Members

1. Theresa Davis, RN, MSN, Inova Health Systems (Chair)

2. Steve Dean, Inova Health Systems (IT Administration)

3. Elizabeth Thomas, InTouch

4. Herb Rogove, DO, FCCM, C3O Telemedicine

5. William Jackson, MD, MBA, InovaHealth Systems (Representing ACCP)

6. Carol Olff, RN, MSN, John Muir Health

7. David Morledge, PhD CCC‐A, DuPuySpine Inc

8. Susan Goran, RN, MSN, MaineHealthVitalNetwork

9. Rebecca Rufo, RN, DNc, Resurrection Healthcare

10. Connie Barden, RN, MSN, Miami Health (Representing AACN)

11. Jim Marcin, MD, MPH, UC Davis Children’s Hospital

12. Pat Herr, RN, Avera eICU

13. Edward Loo, Inova Health System (ITI Engineer)

14. Irene Goliash, RN, Philips/ VISICU

15. Theresa Rincon, RN, BSN, CCRN‐E, Sutter SSR eICU

16. Mark Zubrow, MD, FACP,FCCM, University of Maryland (Representing SCCM)

17. Gavish Amnon, VIDYO

18. John Morris, PhD, CISCO

19. Andrew Graley, Polycom


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Thank You

AFHCAN, Alaska Native Tribal Health Consortium, Anchorage, AK

Stewart Ferguson, PhDChief Information OfficerAlaska Native Tribal Health Consortium4000 Ambassador Drive Anchorage, AK 99508

(907) 729‐[email protected]

The Challenges of an Integrated Telehealth Care Delivery...

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