Transcript Stewart Ferguson Ph.D., Director of Telehealth, ANTHC

Stewart Ferguson Ph.D., Director of Telehealth, ANTHC
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49% of all physicians in Alaska
are primary care physicians
(2002 data)
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U.S. average is 28%
Alaska is 48th in “doctors to
residents” ratio
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65% are located in Anchorage
Shortages in many specialties
25% Alaskans (46% of Alaskan
Natives) live in communities of less
than 1000 people.
579 Community Health Aides in
200 villages provide nearly ½
million encounters each year.
Historically, Alaskan
health care has
incorporated a public
health mission and
primary care focus, and
is less reliant on
specialty acute care
than other parts of the
country.
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Rural residents travel an average of 147 miles one way for
access to next level of care.
Point Hope
Kotzebue
Anchorage
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8 year Operational History
◦ 12,000 cases / year
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Research and Production Telehealth
System
◦ Manufacturing of Medical Devices
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Whole Product Solution
◦ Design  Installation  Training  Support  Marketing
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Installed Customer base includes:
◦ Alaska: 248 sites, 44 organizations
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37 Tribal organizations
US Army sites (6) & US Air Force bases (3)
State of Alaska Public Health Nursing (26)
US Coast Guard clinics (5)
US Coast Guard cutters and ice breakers (6)
◦ Lower 48, Panama, Greenland
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14000
12000
10000
Telehealth Cases
Created
8000
6000
4000
2000
0
2001
2002
2003
2004
2005
2006
2007
10000
8000
Patients Involved in
AFHCAN Telehealth
6000
4000
2000
0
2001
2002
2003
2004
2005
2006
2007
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Managed as Department within Division of
Health Information Technology, ANTHC
 Funded through IHS annual appropriation
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Staffing (funded positions)
◦ Product Development: 12 staff
 Software Development, Testing, Systems Integration,
Technical Writing
◦ Program Development: 8 staff
 Clinical Director, Training and THCs, Support, VtC
◦ Administration and Support: 5 staff
 Director, Admin staff, Sales/Marketing, Warehouse
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Rich, Minimal Data Needs
Electronic
Medical Record
(Organization A)
Billing
System
Electronic
Medical Record
(Organization B)
Telehealth
System
Billing
System
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A Primary Care Tool
• 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
• Urgent Care / Critical Care
– Video Camera
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Base Cart include:
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Metal Frame
Isolated Power System
CPU and LCD Touchscreen
Expansion Ports for USB, RS232,
Video In/Out, External Display
Supported Peripherals:
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Video Otoscope
Digital Camera
Scanner
Video Conferencing
ECG
Spirometer
Tympanometer
Audiometer
Dental Camera
Vital Signs Monitor
External Scopes
Stethoscope (due in ‘08)
Ultrasound (due in ‘08)
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Use for telehealth and
general purpose
auscultation
◦ Single unit can send & receive
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Outputs
◦ Audio output to headphones
◦ USB output (for PC)
◦ TCP/IP output
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Controls
◦ Volume
◦ On/off switch
◦ Send/receive buttons
◦ Independent D/B at both ends
◦ Remote controllable via telnet
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Permanently attached
headphones & chestpiece
Small size
Internal storage for sounds
◦ Saves data in standard file
format
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Excellent freq response
Active noise cancellation
LCD display
◦ Select a unit to connect to
◦ Store/send sounds
◦ Battery level
Power
◦ Rechargeable battery
◦ Auto timeout to save power
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Simplicity is key
for Case Creation.
 Minimize need for
keyboard skills
 Touchscreen
 Color coded
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Rich Web
Interface for
Specialists
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Multi-Lingual
Support
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Fitting Existing Clinical Workflow
• The AFHCAN software
supports existing
referral patterns …
– The software enables
and facilitates healthcare
delivery without
generating new business
rules.
Organization A
AFHCAN
Cart
PHYSICIAN
• Trust Relationships can be
established between one
or many organizations
AFHCAN
Node
AFHCAN
Server
Internet
USCG – multiple WANs
AFHCAN
Cart
PHYSICIAN
AFHCAN
Cart
PHYSICIAN
• … and serves as a
platform for new clinical
relationships.
AFHCAN
Network
AFHCAN
Server
AFHCAN
Cart
PHYSICIAN
AFHCAN
AFHCAN
Code Update
Node
Server
AFHCAN
Server
AFHCAN
Node
AFHCAN
Server
Provides controlled,
secure and robust data
sharing consistent with
HIPAA Privacy and
Security requirements
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Physician’s surveyed at the point of care … on
a per-case basis.
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Did viewing this telemedicine
case/image affect PATIENT TRAVEL
for diagnosis or treatment of this
case (compared to a phone consult)?
• It PREVENTED Patient Travel
• It CAUSED Patient Travel
• It had NO EFFECT
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Patient travel is
prevented for
almost 80% of all
specialty
consults.
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Travel is
prevented for
about 20% of all
primary care
cases.
Primary Care
Specialty Consults
Responses were
received to the
travel question
on 13,510 cases
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Number of Cases
% Preventing Travel
Number of Patients
Avoiding Travel
Savings
Primary Care
Specialty Consults
Annual TOTAL Annual TOTAL
(2007)
(2007)
8614
38,061
2605
10,685
20.5%
20.7%
77.8%
72.5%
1763
7884
2026
7743
$0.79 m $3.55 m $2.73 m $10.45 m
Travel savings generated by the use of AFHCAN telehealth
amounts to approximately $14 million for 15,600 patients.
Annual travel savings, based on 2007 data, is approximately
$3.5 million for 3,800 patients
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Delivering quality healthcare in Alaska, with a population of
636,932 (US Census 2000) in 586,412 miles is challenging.
Population density of 1.1 persons per square mile, 75% of
the state is not connected to a road system and relies on
dangerous small plane travel.
National Travel and Safety Board (NTSB) reported 436
commuter aircraft accidents in 1990-2004 in Alaska. This
is equivalent to 2.8 accidents a month and accounts for
36% of all commuter aircraft accidents in the US.
30%
25%
20%
15%
10%
5%
0%
Primary Care
Specialty Consults
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Primary Care Number of Cases
Specialty
Consults
% Prevent Travel
% Cause Travel
% No Effect
Number of Cases
% Prevent Travel
% Cause Travel
% No Effect
Org
#1
Org
#2
2,243
9.9%
8.8%
81.4%
644
68.6%
7.6%
23.8%
1,273
33.6%
13.3%
53.1%
2,707
73.7%
6.3%
20.0%
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35%
30%
25%
20%
15%
10%
5%
0%
% Caused
% Prevented
% Caused (Trend)
% Prevented (Trend)
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2500
2000
1500
Village Clinics
1000
SubRegional Clinics
Regional Hospital
500
0
2005
2006
2007
2008
(Proj)
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Extending Care to the Village
Pilot project
providing
audiological
services at the
village clinic.
“Having [the audiologist] go out to the villages is
a huge financial benefit.
[She] saw 20 patients a day in Selawik which
saved us $2400.00 in airfare alone, since those
patients would have to be flown to Kotzebue for
the same service. Since most of the patients she
saw were minors, you can add on another
$2400.00 for a parent to accompany the child.
On top of that, the child misses a day of school,
the parent misses a day of work, and there are
usually other children in the family whose care
must be arranged.”
Leslie Neely RN
Case Manager, ENT Clinic,
Kotzebue, AK
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Traveling Audiologist
Travel Avoidance = Cost Savings
Traveling Audiologist Program
Patient Travel Prevented
Based on Outcomes of:
• Unnecessary & cases were archived without sending
• Referred for monitoring
• Take off ENT list - done
Assumptions:
• Only travel to hub is being saved.
• Escort required if patient less than 18 years old
• No lodging / per diem calculated
Net Savings in Travel Costs
Realized by Program
Patient
Visits
1,458
($141,000)
755
$310,000
Cost
Note: 502 less
than 18 yrs old
$169,000
(120% ROI)
Outcomes
27%
26%
23%
19%
15%
5%
Unnecessary & Referred for
cases were
monitoring
archived without
sending
Meds started
Referred to
regional ENT
clinic
Surgery or
Refer to other
testing
specialty
recommended
at ANMC
About 69% of the patients seen needed something done (meds,
surgery, ongoing monitoring) and 27% needed to be screened out.
Note: Percentages may not add to 100% due to multiple outcomes per case.
ACT
STUDY
PLAN
DO
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100.0%
80.0%
18.4%
2.6%
18.6%
4.7%
78.9%
76.7%
60.0%
40.0%
20.0%
0.0%
2006
% Prevented
2007
% Caused
% No Effect
80% of all consult
prevent patient travel
Each year, 1 to 2
cases caused travel
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Greater Efficiency of Existing Resources
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600
5
500
4
400
3
300
2
200
Telehealth Cases (by CY)
1
Average Wait
Telehealth Cases per year
Wait Time (months)
6
100
Avg Wait Less 1.5 months
0
0
Data courtesy of Phil Hofstetter
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5.0
Average Wait Time (months)
4.17
4.0
3.0
2.87
2.15
2.0
1.0
0.0
Pre-Telemed With Telemed With Telemed
(1991-2001) (2002-2004) (2005-2007)
Data courtesy of Phil Hofstetter
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Percent Appointment Availability With 5
Month or Longer Wait Time
50%
47%
45%
40%
35%
30%
25%
20%
15%
8%
10%
3%
5%
0%
Pre-Telemed
(1991-2001)
With
With
Telemed
Telemed
(2002-2004) (2005-2007)
Data courtesy of Phil Hofstetter
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Percent Appointment Availability Within 3
Month Wait Time
100%
90.00%
90%
80%
70%
65.22%
60%
50%
40%
34.87%
30%
20%
10%
0%
Pre-Telemed
With
With
(1991-2001) Telemed
Telemed
(2002-2004) (2005-2007)
Data courtesy of Phil Hofstetter
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Meeting “Standards of Care”
• Post-surgical followup 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.
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Overall Image Rating
35%
30%
25%
20%
Study #1
Study #2
15%
10%
5%
0%
Very Poor
Poor
Adequate
Good
Excellent
Statistic
Originating Site
Average Time / Case
Std. Dev.
Median Time / Case
30.4 minutes
28.6 minutes
20.5 minutes
Consultant
Site
11.3 minutes
16.3 minutes
6. 0 minutes
Cumulative Histogram
100%
% of Cases
80%
60%
CONSULTANT Org.
40%
INITIATOR Org
20%
0%
1
10
Time (min)
100
4,457 consult requests
received at ANMC from
September 2006 to September
2008.
1.4
1.2
Work Days
1.0
0.8
0.6
0.4
0.2
0.0
Q4
2006
Q1
2007
Q2
2007
Days to Review
Q3
2007
Q4
2007
Q1
2008
Q2
2008
Days to Complete
Q3
2008
ANMC provides same day
turnaround time on 65% of all
telehealth cases, and
completes 84% of all telehealth
cases by the next business
day.
Average response rate for
“same day” turnaround is 2.5
hours.
50% of all cases being turned
around in one day are actually
turned around in 1 hour.
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2002
2003
2004
2005
2006
Annual Consult Time (days)
20.0
18.0
16.0
14.0
12.0
10.0
8.0
6.0
4.0
2.0
0.0
2007
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Telehealth Surgical Referrals
• A review of 56 telehealth cases
that led to direct surgical
referrals found:
• 92.9% accuracy in predicting
procedure
• 31 minute average difference in
predicted versus actual operative
time.
30%
25%
20%
15%
10%
5%
0%
-3
• By comparison, a matched
selection of 56 non-telehealth
referrals for surgery:
• 87.5% accuracy in predicting
procedure
• 36 minute average difference in
predicted versus actual operative
time.
-2
-1
0
1
Hours (Actual - Estimate)
Non Telehealth
2
3
Telehealth (Matched)
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Avg Monthly Caseload
Average case load was 2.6
cases/month prior to the
CME visit.
14
12
10
8
This rose to 7.9 cases/month
for each organization and
was sustained for 18 months
after the CME visit.
6
4
2
0
-48
-36
-24
-12
0
TIME Relative to CME/Training (months)
Before CME
After CME
AVG (Before)
AVG (After)
12
The net effect is that
approximately 250 more
patients are being seen per
year
These 250 visits represent a
savings in 80 man-years of
waiting time.
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For this case, rate the following statement:
Telemedicine helps me
COMMUNICATE with a
doctor. (n=2,672)
Strongly Disagree
4%
Disagree 0%
Neutral
Agree
Strongly Agree
8%
39%
49%
45
64%
Helped EDUCATE patient
76%
Made JOB MORE FUN
77%
Improved PATIENT SATISFACTION
86%
Improved QUALITY OF CARE
88%
Helped COMMUNICATE with doctor
(N=2,605)
(N=2,852)
(N=2,441)
(N=2,512)
(N=2,672)
Percentages of cases created to which the provider
“Agreed” or “Strongly Agreed” with the statement.
95%
90%
85%
80%
75%
70%
65%
60%
2001 2002 2003 2004 2005 2006 2007
Telemedicine helps me
COMMUNICATE with a
doctor.
Telemedicine will
improve the QUALITY
OF CARE for this
patient.
I am SATISFIED with
how the EQUIPMENT
worked.
The telemedicine
system played a role in
EDUCATING THIS
PATIENT.
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Closing the BIG Loop
• Review of 28,000
images
– Selected 2,403 training images
• 75 different categories
• 30 educational modules
AOM
Auricular trauma
Auricular trauma: Hematoma
Blunted TM
Bullous myringitis
Canal pathology
Canal pathology: Foreign body
Canal pathology: Fractures
Canal pathology: OE
Canal pathology: Soft tissue
Canal pathology: Trauma
Canal stenosis
Cerumen
Cholesteatoma
Cholesteatoma: Intra op
Cochlear implants
Congential ear anomalies
Congential neck masses
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Different strokes
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Cardiology
CHA/P Training
Dermatology
Endocrinology
Emergency Room
ENT
Ophthalmology
Inpatient Pediatrics
Neurosurgery
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Pediatric Critical Care
Podiatry
SCF Pediatrics
SCF Family Medicine
SCF Women’s Health
Surgery
Urology
Trauma Follow-Up
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Specialty Consults
(Percent of Total Cases)
30%
100%
25%
80%
20%
60%
15%
40%
20%
10%
0%
5%
ORG. #1
ORG. #2
ORG. #3
ORG. #4
ORG. #5
17091 Cases 12855 Cases 6185 Cases 6157 Cases 1349 Cases
0%
2001
2002
2003
2004
2005
2006
2007
Specialty Consults as a
Percent of Total Cases
PRIMARY CARE Cases
SPECIALTY CONSULT Requests
Variations In Organizational
Usage Patterns
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2.6
2.4
2.2
2.0
1.8
1.6
1.4
1.2
1.0
0.8
0.6
0.4
0.2
0.0
2001
2002
2003
2004
2005
2006
2007
The growth in telehealth is indicative of a
growth in access to care.
Growth was in
fact due to more
patients being
involved in
telehealth.
1 to 1.5 cases
per patient per
year –
regardless of
the overall
growth.
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Now what?
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AFHCAN Carts
4 Yr
Project
275
5 Yr
Project
250
225
200
175
Deployed
Connected to Server & Network
Regular Usage (10 Real Cases)
Sustained Usage (50 real Cases)
Standalone
150
125
100
75
50
25
r-0
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Fe
b02
Ap
r-0
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Ju
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Au
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Ap
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Au
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01
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643 providers actively participated in
telehealth encounters.
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50% participated in 10 or fewer encounters.
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80% participated in 40 or fewer encounters.
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6% participated in more than 150 encounters.
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AFHCAN provides training
in many different areas
such as:
◦ Installation and cable
management
◦ Software administration for IT
specialists
◦ Clinical use of biomedical
equipment
◦ Clinical use of telemedicine
software
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More than 20 manuals
have been developed to
augment the training
and support provided
by our staff.
Training Offerings:
Didactic classes
Web based training
Manuals
Ongoing monthly basis in
Anchorage
◦ On-site training in the regions
◦ CMEs and CEUs available for
many classes.
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Classes include:
Desktop User
New User Training
Training Refresher
System Administrator
Train-the-Trainer
Workshop
◦ Non-Clinical Orientation
◦ Cart Hardware Upgrade
Procedure
◦ Orientation to U.S.
Telemedicine, for
International Doctors
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Yakama
IHS Southern Bands
Red Lake
Walker River Paiute
Goshute Indian Res. (3)
•Moapa
•Duckwater
•Wahoe
Shiprock
Catawba
IHS Expansion – Consultants
Childrens Mercy Hosp
• Pediatric Orthopedics
National Jewish MC
Alaska Native MC
• ENT
• (Others)
• Pulmonology
• Immunology
Ft. Defiance Indian Hosp.
San Francisco VA MC
• Neurology
Shiprock
• Pediatrics
IHS Ctr for Telehealth
•Nat. Amer. Cardiology Prog.
Univ. of New Mexico
• Pediatric Orthopedics
AFHCAN Node Server
Anchorage, Alaska
Arizona Telemedicine-Tucson
Anchorage, Alaska
Internet Node Secondary
Anchorage, Alaska
Internet Node
Anchorage, Alaska
IHS Yakama
Anchorage, Alaska
ANMC
IHS Node
Anchorage, Alaska
Alaska Native Medical Center
Anchorage, Alaska
IHS Catawba
Univ. of New Mexico
IHS Red Lake
IHS Nashville Area Server
(VMWare)
Nashville, Tennessee
San Francisco VA MC
Childrens Mercy Hosp KC National Jewish MC-Denver
IHS Consultant Servers
(VMWare)
Anchorage, Alaska
IHS Shiprock
IHS Ctr for Telehealth
Non-IHS Network
Alaska Native
Organization Servers
Walker River Paiute
IHS Southern Bands
Goshute Indian Reservation
IHS Phoenix Area Server
(VMWare)
Phoenix, Arizona
IHS Network
Drawing Key:
Solid Lines = Node Connections
Dash Lines = Server to Server Trust Relationships
Cloud = Represents multiple servers too numerous to list
Boxed Grouping of Servers = Virtual Servers on one physical host
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One Clinic Referral - Concept
Regional Hospital
Alaska Native Medical Center
Department
Referral
Request
Referral
Office
Front Desk
Case Managers
Referral
Complete
Assistant Case
Managers
Physicians
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Clinical Needs
Urgent Care / Critical Care
Behavioral Health
Palliative Care
Case management
Cardiology ultrasound
Discharge planning
Presurgical planning,
postsurgical follow-up
◦ Pediatric ultrasound
◦ Rheumatology
◦ Trauma
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Other Needs
◦ Connecting families
from Quyana House
to their families back
home
◦ Supervision and
mentoring of remote
clinical staff
◦ Professional support
to remote clinical
staff
◦ Distance Education
◦ Administrative
meetings

Multipartner Sites: ANMC (11), SCF (6), ANMC/SCF
(2), ANTHC (16), AFHCP Office (1).
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Connectivity to multiple networks
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 (ARTN, Providence, ATHS, ConnectMD, IHS)
Conference Room system (1), Training Room (1),
Wall Mount endpoints (14), Mobile Cart endpoints
(20)
Upgrade Core bridge, Management software. New
Border Controllers, Content Management Node
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Travel one (1) expert from each of the 8
partners to Outside organizations each year.
 Travel to high usage VtC programs
 E.g. OTN, ATP, Montana, etc.
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Alaska Statewide Broadband (Telehealth)
Summit.
 Year 2 activity
 Share expertise, successes, failures, lessons
learned.
 Include ALL Alaska health care providers involved in
VtC.
Thank You
AFHCAN, Alaska Native Tribal Health Consortium, Anchorage, AK