1. The AFHCAN Telehealth Program
Stewart 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 Native Tribal Health Consortium 1

2. ALASKA
• 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 National Travel and
states combined. Safety Board (NTSB)
reported 436
• 47th in road miles commuter aircraft
– 75% Alaskan communities unconnected by accidents in Alaska
a road to a hospital. from1990-2004 (2.8
– 25 of these have no airport. accidents a month) -
accounting for 36%
of all commuter
• Population density is 1.1 persons/mile2 aircraft accidents in
– 70 times smaller than the national average. the US.
Alaska Native Tribal Health Consortium 2

3. 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
DISPARITIES: MD 73.9 220.6 66% Lower
Health Staff per
DD 24.0 61.8 61% Lower
100,000 people
Nurse 229.0 849.9 73% Lower
Alaska Native Tribal Health Consortium 3

4. Rural residents travel an average of 147 miles one way
for access to next level of care.
Point Hope
Kotzebue
Chicago Ann Arbor
Anchorage
Washington DC
Alaska Native Tribal Health Consortium
4

5. CONTEXT
ALASKA NATIVES ARE
THE HEALTHIEST PEOPLE
IN THE WORLD
ANTHC VISION
Alaska Native Tribal Health Consortium 5

6. Years of Potential Life Lost, Alaska Natives, 2004-08
Unintentional Injury (n=451)
Suicide (n=250)
Cancer (n=555)
Heart Disease (n=328)
Chronic Liver Disease (n=114)
Homicide (n=56)
Cerebrovascular Disease (n=70)
Pneumonia/Influenza (n=35)
COPD (n=96)
Diabetes (n=39)
n=number of deaths
before age 75 years 0 5000 10000 15000 20000
Source: Alaska Epidemiology Center,
Alaska Native Tribal Health Consortium
ANTHC; Alaska Bureau of Vital Statistic

7. Alaska Native Tribal Health Consortium

8. 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 Native Tribal Health Consortium 8

9. 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.
Alaska Native Tribal Health Consortium
9

10. Designing 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
Alaska Native Tribal Health Consortium 10

11. A User Interface Designed by Users
11
Alaska Native Tribal Health Consortium

12. AFHCAN Telehealth Program
Cases Created per Year  Managed by ANTHC
 Federally funded
35,000
30,000
25,000
 28 Staff
Cases Created
20,000
15,000
10,000
 11 year Operational History
5,000  33,000 cases/year
0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011  131,628 Cases (ATHS)
Installed Customer base includes:
 Alaska: 248 sites, 44 organizations
59 operational systems in 2011
1,443 providers in 2011
22,763 patients in 2011 (16% of AN pop)
 Other states and countries
Alaska Native Tribal Health Consortium 12

13. THE ROLE OF TELEMEDICINE
Alaska Native Tribal Health Consortium 13

14. We only assume
patients travel to
nearest region
Alaska Native Tribal Health Consortium 14

15. Audiology
Cardiology
Care Coordination
Role of Telemedicine Center
Dental
Dermatology
Emergency
• S&F • VtC Department
Endocrinology
– 3% of encounters – Cardiology Family Medicine
– Primary Care (75%) – Liver/Hepatitis Gastroenterology
HIS
– Specialty Care (25%) – Pediatrics Internal Medicine
Neurosurgery
– Triage / Planning – Breast Cancer Opthalmology
– Discharge Planning Screening Orthopedics
Otolaryngology
– Esoteric : Abuse … – Mental Health / API Pediatrics-
Outpatient
Podiatry
Pulmonology
– Teleradiology • RPM Rheumatology
– Telepharmacy Surgery
Urology
Women’s Health
Alaska Native Tribal Health Consortium 15

16. By the numbers …
131,628 Cases created
65,314 Patients served
2,968 Providers involved
1,854 Providers creating
ATHS (Alaska Tribal Health System)
(1/1/2001 to 3/31/2012) Alaska Native Tribal Health Consortium 16

17. IMPACT OF TELEMEDICINE
Alaska Native Tribal Health Consortium 17

18. Why do you do 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%
• Best for patient care
• Increased access for care
Alaska Native Tribal Health Consortium 18

19. Telehealth Impact on Extended
Waiting Times (> 4 months)
50% 47%
Percent Appointment Availability With 5
45%
40%
Month or Longer Wait Time
35%
30%
25%
20%
15%
10% 8%
5% 3%
0%
Pre-Telemed With With
1991-2001 Telemed Telemed
(n=1216) 2002-2004 2005-2007
(n=276) (n=210) Data courtesy of Phil
Hofstetter
Alaska Native Tribal Health Consortium 19

20. Joslin Vision Network (JVN)
Portable JVN Pilot
Deployment of the IHS-JVN in Alaska using a portable
platform reversed a seven year decline in rates for the state
70%
15% Increase
60%
50%
DR Exam Rate
40%
30%
25% Decrease Portable JVN
20% implemented
10%
0%
Alaska Native Tribal Health Consortium 20

21. Pre-Operative Planning for Ear Surgery Using
Store-and-Forward Telemedicine
John Kokesh M.D., A. Stewart Ferguson Ph.D., Chris Patricoski M.D.
40%
The average
35%
difference was not
Percent of Patients
30%
statistically
25%
different between
20%
NonTelemed the two groups:
15%
Telemed 32 minutes for the
10%
telemedicine
5%
evaluation group
0%
and 35 minutes
-3 -2.5 -2 -1.5 -1 -0.5 0.5 1 1.5 2 2.5 3
for the in-person
Actual Surgical Time - Planned Surgical Time (hrs)
evaluation group
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)
Alaska Native Tribal Health Consortium

22. Annual Travel Savings (by Case Role)
$7,000,000
$6,000,000
$5,000,000
$4,000,000
$3,000,000
$2,000,000
$1,000,000
$0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Primary Care Specialty Care
Alaska Native Tribal Health Consortium 22

23. Speed of Reply
Turnaround Time
1 Day Same Day 4 Hour 2 Hour 1 Hour
100%
91%
80%
73%
% Cases
60% 59%
40% 43%
28%
20%
0%
Alaska Native Tribal Health Consortium 23

24. How important is the speed of reply?
(% “Extremely Important)
When using AFHCAN for patient care – how important is the speed
of reply of the consulting doctor?
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
High User (Initiator) High User (Consultant) Medium User (Initiator) Medium User (Consultant)
• Speed of response is clearly more important to Initiators compared to
Consultant
• High User Initiators - 43% rated this 5 out of 5 (“Extremely Important”)
Alaska Native Tribal Health Consortium
24

25. THE FINANCIAL MODEL FOR TELEHEALTH
Alaska Native Tribal Health Consortium 25

26. Medicaid-Eligible Patients
Medicaid
Medicaid Payments
payments $70,000
totaled $60,000
$269,893 to $50,000
$40,000
ANMC for $30,000
specialty $20,000
$10,000
telehealth $0
consults. 2003 2004 2005 2006 2007 2008 2009
A total of 5,925 telehealth specialty
consults with provided to 3,663 unique
patients.
Alaska Native Tribal Health Consortium 26

27. We only assume
patients travel to
nearest region
Alaska Native Tribal Health Consortium 27

28. Medicaid Study: 2003-2009
Decreased Travel = Cost Savings
Quantity Cost
Claims Paid by Medicaid 4,482 ($269,894)
Telemedicine Prevented Travel 3,662 $3,116,034
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
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
Alaska Native Tribal Health Consortium 28

29. 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
Alaska Native Tribal Health Consortium 29

30. 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
Alaska Native Tribal Health Consortium 30

31. THE FUTURE
Alaska Native Tribal Health Consortium 31

32. The New Limiting Step
Alaska Native Tribal Health Consortium

33. Growing Usage
100%
90%
80%
70% High & Medium Users (11 YR) n=14
60%
High & Medium Users (10 YR) n=10
50%
40% High & Medium Users (9 YR) n=6
30%
20% High & Medium Users (8 YR) n=5
10%
0% 100%
1 2 3 4 5 6 7 8 9 10 90%
80%
70% High & Medium Users (10 YR) n=8
60%
High & Medium Users (9 YR) n=13
50%
40% High & Medium Users (8 YR) n=5
30%
20% High & Medium Users (7 YR) n=4
10%
0%
1 2 3 4 5 6 7 8 9 10
Alaska Native Tribal Health Consortium 33

34. Improve Performance with Scale
Cases Created per Year
4,000 • Good will and
3,500
3,000 commitment
Cases Created
2,500
2,000 • Earned time off for
1,500
1,000 volume done
500
0
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
• Provider time allocated
(Proj)
to telemedicine
Median Turnaround Time (hrs)
3.5 • Financial incentive to
Median Turnaround Time (Hrs)
3.0
2.5
do the “additional”
2.0
1.5
work
1.0
0.5
0.0
2010 Q4 2011 Q1 2011 Q2 2011 Q3 2011 Q4 2012 Q1
Alaska Native Tribal Health Consortium

35. 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
Alaska Native Tribal Health Consortium 35

36. Technology is a STRATEGY to
improve performance
and to manage
costs & risk

37. 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.
Alaska Native Tribal Health Consortium 37

38. 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
Alaska Native Tribal Health Consortium 38

39. sferguson@anthc.org
Alaska Native Tribal Health Consortium