The document discusses telehealth initiatives in Virginia, including the Virginia Telehealth Network (VTN) and the Virginia Stroke Systems (VAST) pilot program. VTN aims to improve healthcare access across the state through telehealth, starting with an acute stroke care network. The VAST program will test an integrated stroke system across central Shenandoah Valley using telemedicine, including remote neurology consultations via robot, to evaluate and treat stroke patients in rural hospitals. The goal is to create a replicable model to improve stroke outcomes and reduce disability statewide.
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Virginia's Telehealth Network and CAH-HITN Program
1. Telemedicine and Telehealth:
The Virginia Telehealth Network
and Virginia’s CAH-HITN Program
Kathy H. Wibberly, Ph.D.
Director, Division of Primary Care and Rural Health
September 23, 2008
1
What Is Telehealth?
Simply defined as:
The use of information and telecommunications
technologies to distribute health services and
education across or between health care
systems.
2
Telehealth Defined
In reality, much more complex…
Telehealth is an organizational business practice
using a combination of clinical, technical and
business processes supported by policy, which
policy,
enables an health-related organization or health
health-
care institution to dynamically exchange
electronic health information, health services
and health education between providers, and/or
providers and patients to facilitate the delivery of
health care services.
3
1
2. Telehealth Defined
Ideally, all healthcare encounters should be
captured in a longitudinal multi-media electronic
multi-
health record, however, few exist.
Related terms/fields: E-Health, Telemedicine,
E-
Informatics, HIT, and other forms of medical
communications
4
Scope of Telehealth
5
Fit for Telehealth
Population-
Population-based (seniors, children, immigrants, etc.)
Disease Management (chronic diseases, asthma, melanoma,
mental health etc.)
Emergency Services (urgent and emergent care during a
natural disaster or other crisis)
Diagnostic Interpretation & Treatment
Quality-
Quality-Improvement (improving an existing service)
Cost Avoidance/Other System Benefit (decrease travel,
reduce medical errors, reduce redundancy of medical tests,
improve prescribing practices, etc.)
6
2
3. Virginia Telehealth Network (VTN)
The concept of VTN was spearheaded
in 2002 by the Division of Primary Care
and Rural Health
It began as an informal coming together
of healthcare stakeholders sharing a
common desire to address inequities in
access to healthcare services using
telehealth
7
Virginia Telehealth Network (VTN)
Historical approach to telehealth in Virginia
Applications designed and developed by each
institution driven largely by reimbursement
schemes
Clinical applications are VTC-based medical
VTC-
specialty consultations or tele-radiology
tele-
No central focus on a particular health
problem
8
Snapshot of Telehealth Equipped
Sites in Virginia (December 2003)
U.V.A.
X= hub
Community Service Board
= point of presence (POP)
V.D.H.
Winchester
D.O.C.
Leesburg Arlington
RAHEC
Falls Church
EVTN Woodstock Front Royal
VA Dept. of Mental Health (VDMHMRSAS) Fairfax
(2) Alexandria
VCU. Manassas
VT/VCOM
Warrenton
Harrisonburg
Monterey Culpepper
Fredericksburg Colonial Beach
Dahlgren
(2) (2)
Craigsville Staunton Montross
Mitchells Olney
Warsaw
Hot Springs Charlottesville St Stephens Church Accomac
Bowling Green Callao
Troy
Clifton Forge Ashland (2) Heathsville
Coving- Aylett Tappanahanock (3) Kilmarnock (4) Nassawadox
ton Low Moor Goochland Glen Allen
Dillwyn Saluda Belle Haven Franktown
Lexington
(2) (2) Vinton Lancaster
New Castle Powhatan Richmond
Grundy Lynchburg (11) Chesterfield Hartfield
Blacksburg Roanoke Farmville (3) Charles City Cheriton
Vansant (2) Madison Heights Petersburg
Clintwood Salem X
Bastion (2) Williamsburg
Tazewell Christianburg Hayes
Pound Pearsburg Blackstone
Hampton
Dungannon Cedar Bluffs Bland
Newport News
Wise Newport News
Big Stone St. Paul Wytheville Radford Burkeville (17)
Gap Lebannon Saltville Blacksville Catawba Portsmouth Norfolk Virginia Beach
Pulaski Boydton Jarratt (3) 2-H
Norton Marion Floyd Martinsville
Abington (2)
Hillsville Laurel Fork South Boston
Pennington Gate City Konnarock Galax Suffolk Chesapeake
Danville
Gap Stuart
Bristol
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3
4. Isolated Networks
Hospitals
VCU
VDH
VT/VCOM
Dept. of Corrections
VDMHMRSAS/CSB
UVA
10
The Birth of a Vision
VT/VCOM
VDH VCU
VDMHMRSAS/CSB
Other Networks Virginia
Telehealth Network
Dept. of Corrections
EMS-
Satellite
Home health Provider
UVA Geriatric patients offices
facilities
11
Virginia Telehealth Network (VTN)
Early strategy for VTN (starting in 2004)
Population perspective - access issues and
health disparities
Focus on infrastructure improvements without a
p
specific healthcare orientation
12
4
5. The group’s meetings and planning became
formalized with the incorporation of VTN in August
2006
In 2007,
I 2007 VTN completed its formation by appointing
l di f i b i i
a Board of Directors and Executive Director – now
pending 501c3 status expected by Dec 2008
13
Vision
VTN believes that all Virginians should have access
to high-quality healthcare regardless of their
high-
location — rural, urban or suburban-and that their
suburban-
health information should be securely shared among
providers using technologies that support safe and
timely care delivery when and where it is needed.
14
Mission
VTN devotes its resources to advancing the
adoption,
adoption implementation and integration of
telehealth and related technologies into models of
healthcare statewide-- and promotes the integration
statewide--
of health systems to support the delivery of care for
all Virginians.
15
5
6. Unifying Strategy Adopted
in Spring 2007
Public Health Problem Focus:
Many patients impacted by stroke do not receive the
most advanced stroke treatment possible.
16
http://www.cdc.gov/dhdsp/library/stroke_hospitalization_atlas.htm 17
Acute Stroke Care
“TIME IS BRAIN”
18
6
7. Stroke Evaluation Targets
for Thrombolytic Candidates
Time
Door to doctor 10 minutes
Access to neurological expertise
expertise* 15 minutes
Door to CT completion 25 minutes
Door to CT read 45 minutes
Door to treatment 60 minutes
Access to neurosurgical expertise* 2 hours
Admit to monitored bed 3 hours
* By phone or in person
19
Fragmentation and
Disparities of Care
Virginia Hospitals by Stroke Center Designation
20
Fragmentation and
Disparities of Care
Board-Certified Neurologists in Virginia by Rurality
21
7
8. Fragmentation and
Disparities of Care
call
volume
EMS Time from Call to Arrival at Destination
22
Continuum of Care Framework
23
Scenario Without Integrated Stroke System
Patient (36 yo woman) experiences
stroke symptoms. Family calls
Family physician, 30 min later office
returns call instructs patient to call
911, volunteer EMS alerted from
home, site arrival 36 min,
transported to CAH ED within 3
hours of onset.
• ED physician recognizes stroke symptoms, calls in Patient admitted to CAH Patient discharged from
technician, orders CT, blood tests. floor bed – OT/PT CAH to home PT services
evaluations completed; (inpatient rehabilitation
• CT performed and read by general radiologist, who
no speech pathologist facility preferred)
rules out hemorrhage.
available- aspiration
• No neurologist is available so ED physician diagnoses
available, pneumonia
patient with acute ischemic stroke, but is uncomfortable
treating with t-PA, [closing window] so elects to treat
with aspirin and admit to floor bed
Onset Onset Onset Onset
9.00 PM + 1 hour + 2 hour + 3 hour
ALOS: 5.8 days* Pt unable to return to work – “laid off” – severe
disability
Adapted from May 2006 “Stroke Care of the Future”
* Based on study results presented at ISC Feb 2006 Presentation with permission from SG2
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8
9. Scenario With Integrated Stroke System
Patient (36 yo woman) experiences
stroke symptoms. Family calls 911.
EMS completes F.A.S.T., and Education Improve
glucose screening, instructs family to
ride in ambulance; en route Stroke
Physician
Code is alerted at CAH ER, patient is Telemedicine consult Communication
transported to CAH ED within 40
mins of initial call.
PACS – immediate reading of CT
Patient admitted to N- Patient discharged from
• ED physician confirms stroke symptoms, radiology tech
Community-EMS and lab tech in-house alerted –calls PSC page operator
NICU Unit X 24 hrs – PSC to inpatient
Stroke Unit rehabilitation, and back to
• Neurologist RP7 communication initiated Speech/OT/PT home PT/OT services
Education • CT performed and PACS to Stroke neurologist, who
evaluations completed;
EMR sent to PCP and
MRI-DWI obtained –
rules out hemorrhage referring ED physician
severe carotid stenosis –
• Neurologist reviews inclusion/exclusions for rt-PA ‘ pt has NS procedure
trained ER nurses administer t-PA, trained ambulance next day
crew transports
Onset Onset Onset Onset Onset Onset
9.00 PM + 1 hour + 2 hour + 3 hour + 24 hour + 72 hour
ALOS: 3.8 days* Pt returns to vocation as clerk (supporting family of 3)
25
Adapted from May 2006 “Stroke Care of the Future”
* Based on study results presented at ISC Feb 2006 Presentation with permission from SG2
CAH-
CAH-HITN Grant
VAST-
VAST- Phase 1 Pilot
Being leveraged to set-up the VAST test-bed across
set- test-
the Central Shenandoah Region focusing on Bath
Community Hospital as the CAH.
Design, implement, test and evaluate an integrated
and fully optimized stroke network that can be
replicated state-wide
state-
Eventual goal is to leverage the infrastructure to
support other healthcare needs– starting with the co-
needs– co-
morbidities of stroke (CAD, HTN, Obesity etc)
26
Virginia CAH-HITN Partners
CAH-
27
9
10. Sub-
Sub-Acute
EMS Care &
Notification Acute Secondary
Prevention/Education & Response Treatment Prevention Rehabilitation
Continuum of Care
Continuous Quality Improvement (CQI)
Interventions Interventions Interventions
Virginia Stroke Systems Website EMS Stroke Plan PACS
Patient/Family/Provider Toolkits EMD/EMT Stroke Remote Consultation
Protocols
Social Marketing Campaign Clinical Protocols
Web-based Learning
National Tele-stroke Conference
Management System
28
Prevention/Education
Interventions
Virginia Stroke Systems Website
http://virginiastrokesystems.org
Content Management System
V d
Vendor: W d il St di
Woodpile Studios
VAST Toolkits (Family, Community)
Stroke Social Marketing Campaign
National Telestroke Conference in Northern VA
Dec 9-10, Co-sponsored by the American
9- Co-
Telemedicine Association
29
EMS
Interventions
Regional EMS Stroke Plan
Enhanced Stroke Protocols
911 Emergency Medical
Dispatch
EMS- First Responders
EMS-
Improved EMS Documentation
Web-based learning management
Web-
system
Vendor:
30
10
11. Acute Stroke - “Telestroke”
RP-7 Images
transmitted
Live Image of
Patient in Rural
CT Scan Remote Site Hospital as Seen (Note image of
By Physician in physician as a
“Stroke Center” part of the 2-way
transmission)
31
RP7 Robot
“Remote Presence”
InTouch Health – deployed now at UVA-BCH
UVA-
~5 foot – 200 lbs – 150 “eyes” – infrared sensors
32
Critical Access Hospitals with RP Technology
CAH locations
33
11
12. 34
Rural Telehealth
Challenges
Weaknesses in health care managerial culture
Lack of understanding of HIT value/benefits by
Providers/Patients
Reimbursement & Capital Costs
p
Aligning Financial Incentives
Driving Cost-Effectiveness (i.e. Chronic Care &
Cost-
Disease Mgmt)
Start-up Costs Capital Investment
Start-
Standards (Clinical & Communications)
Quality & Safety
35
Rural Telehealth
Challenges
Infrastructure Issues
Inadequate and/or Costly Network Infrastructure /
Broadband Access
Interoperability
p y
Human Dimension Issues
Arrangements to Practice in an e-enabled
e-
Environment
Practitioner and Patient Acceptance
Licensure, Accreditation, Certification
Legal (Stark Law, Liability, FDA, HIPAA)
Training an HIT Workforce
36
12
13. Rural Telehealth
Challenges
37
Summary
Telehealth/telemedicine is a growing component
of the health care process and offers solutions to
problems regarding resources and distances.
VTN has been established in Virginia to facilitate
the systematic growth of telehealth/HIT—starting
telehealth/HIT—
with VAST.
CAH-
CAH-HITN grant has been instrumental in
allowing Virginia to achieve goals and objectives
for VAST Phase 1 and helping VTN become
established as an HIT leader
38
VTN Website: http://Ehealthvirginia.org
13
14. Questions?
Kathy H. Wibberly, Ph.D.
Director, Division of Primary Care and Rural Health
Virginia Department of Health
(804) 864-7426
864-
Kathy.Wibberly@vdh.virginia.gov
40
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