Stewart Ferguson PhD Director of Telehealth Alaska Native Tribal Health Consortium

1. The Impact of Telehealthin AlaskaAn 8 Year Retrospective of the AFHCAN Project Stewart Ferguson Ph.D., Director of Telehealth, ANTHC John Kokesh MD, Chief of Otolaryngology Dept., ANMC Chris Patricoski MD, AFHCAN Clinical Director, ANTHC Phil Hofstetter, Director of Audiology, NSHC Nathan Hogge, AFHCAN Senior Software Architect, ANTHC

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4. 75% of Alaskan communities are unconnected by a road to a hospital.

5. 25% Alaskans (46% of Alaskan Natives) live in communities of less than 1000 people.

6. Population density is 70X smaller than the national average.

7. 49% of all physicians in Alaska are primary care physicians compared to U.S. average of 28%

10. Air travel required: Provider Patient

11. Case originated…

12. …Case received.

13. 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”

15. Documents & Images

16. Electronic Medical Records

17. Patient Education

18. Face-to-Face Interaction

20. Dermatology

21. Pathology

22. Oncology

23. Ophthalmology

24. Dental

25. Cardiology

26. ENT

27. GI

28. Pulmonary

29. Rheumatology

30. Psychology/ Psychiatry

31. Neurology

32. Speech therapy

33. Physical therapyClinical specialties for telemedicine 10

35. Can create a case “on the run.”

36. Doctor can respond when available.

37. Many consults are not critical.

38. It is needed as a communication tool.

39. Fits with present model.

40. Minimal onsite technical support is needed.Low bandwidth requirements Static data – e.g. Vital signs Static Images Digital camera (megapixel) Scans Captured video images (ENT, Dental, Opthal., Naso.) Video Clips – esp. from video devices Temporal Data: ECG, stethoscope, tympanometer Textual: Health summaries 11

42. Alaska: 248 sites, 44 organizations

43. 37 Tribal organizations

44. US Army sites (6) & US Air Force bases (3)

45. State of Alaska Public Health Nursing (26)

46. US Coast Guard clinics (5)

47. US Coast Guard cutters and ice breakers (6)

49. TELEHEALTH Team EXECUTIVE BOARD CEO / Commanders ANMC, VA, USCG, 3MDG, BACH, 354 MDG STEERING BOARD AFHCP Planning Board Chairman, AFHCP Project Officer, AFHCP Business Office Director, ANMC Data Manager, and Clinical and Tribal Representatives AFHCAN Partners Clinical Training APO Technology Business OrganizationalChart“Communications” Informatics

50. 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 A Primary Care Tool 15

51. A User Interface Designed by Clinicians Simplicity is key for Case Creation. Minimize need for keyboard skills Touchscreen Color coded 16

52. A User Interface Designed by Clinicians Rich Web Interface for Specialists 17

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56. Agreed upon expectations

57. Sustainable and scalable

58. Accountable

59. Independent of individuals

61. Training More than 20 manuals have been developed to augment the training and support provided by our staff. 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 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. 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

62. How can Telehealth reduce the cost of health care? Physician’s surveyed at the point of care … on a per-case basis. 23

63. Medicaid StudyDecreased Travel = Cost Savings 24 Note: For every $1 spent by Medicaid on reimbursement, $7.95 is saved on travel costs.

65. It CAUSED Patient Travel

67. Impact of Preventing Patient Travel 27 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

68. Impact of Telehealth on Causing Patient Travel 28

69. Providing Care in the Patient’s Community 29

70. Traveling AudiologistTravel Avoidance = Cost Savings

71. Outcomes 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.

72. Three remote sites (Jan ‘09) 96 Patients imaged 66 patients  follow up in 12 mo. 30 patients have pathology that require an in-person visit with an ophthalmologist 11 with diabetic retinopathy 19 with additional pathology: Large optic cups, hard exudates, macular drusen, pseudophakia, ungradeable images with hx IHS/JVN Alaska Diabetic Retinopathy is the leading cause of new blindness among adults Blindness due to diabetes can be eliminated by timely Dx and Tx

73. Expert Triage Model 33 80% of all consult prevent patient travel Each year, 1 to 2 cases caused travel

75. Average Wait Time 35 Data courtesy of Phil Hofstetter

76. Waiting Times> 4 Months 36 Data courtesy of Phil Hofstetter

77. Improving Processes 37

80. ANMC: Access To Care 40 4,457 consult requests received at ANMC from Sep 2006 to Sep 2008 Median Time Spent by a Consultant Responding to a Case ANMC provides same day turnaround time on 65% of all telehealth cases, and completes 84% of all telehealth cases by the next business day. 50% of all cases being turned around in one day are actually turned around in 1 hour. Average response rate for “same day” turnaround is 2.5 hours. Median Time per Case

81. Dermatology CME Visits 41 Average case load was 2.6 cases/month prior to the CME visit. This rose to 7.9 cases/month for each organization and was sustained for 18 months after the CME visit. 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.

82. 42 For this case, rate the following statement: Telemedicine helps me COMMUNICATE with a doctor. (n=2,672)

83. 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. Hiring Providers 43

84. 44 For this case, rate the following statement: Telemedicine makes my JOB MORE FUN. (n=1,897) “Each village trip I receive innumerable positive "amazing" comments from patients and parents about how wonderful this technology is for them. … I think the advanced cutting edge technology of telemedicine has actually kept my professional interest in staying within this region.”

85. The Hand Switch “I was able to see the problem - then the repaired normal condition - and discussed my problem - very informative!” 45

86. 46 For this case, rate the following statement: The telemedicine system played a role in EDUCATING THIS PATIENT. (n=2,605)

87. Closing the BIG Loop Review of 28,000 images Selected 2,403 training images 75 different categories 30 educational modules 47

88. PROVIDER Responses Percentages of cases created to which the provider “Agreed” or “Strongly Agreed” with the statement.

89. Consultation Model 49 Regional Hospital Alaska Native Medical Center Department ConsultationRequest Front Desk Patient Registration Case Managers EHR ConsultationComplete Assistant Case Managers Physicians

90. Telehealth solutions offer much more than the simplified concept of remote consultation through access to remote specialists. A properly designed telehealth system can create great efficiencies through expert triage models, discharge planning, presurgical planning, post-surgical follow-up, care coordination, traveling providers, and other clinical workflow patterns. Learning from Experience 50

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92. Thank You AFHCAN, Alaska Native Tribal Health Consortium, Anchorage, AK