Developing Large Scale, MultiAgency, MultipleProvider Type Telehealth Solutions for Alaska

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Developing Large Scale, Multi-Agency,
Multiple-Provider Type Telehealth Solutions for
Alaska
Mission To provide the highest quality health
services for all Alaska Natives. Vision A
unified Native Health System, working with our
people, achieving the highest health status in
the world.
Presented by Paul Sherry Chief Executive Officer
October 2003
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Developing Large Scale, Multi-Agency,
Multiple-Provider Type Telehealth Solutions for
Alaska
Mission To improve access to health care for
federal beneficiaries in Alaska through
sustainable telehealth systems
Presented by Paul Sherry Executive Committee
October 2003
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Alaska Federal Health Care Partnership

• Veterans Affairs
• DoD (Army Air Force)
• DoT - (USCG)
• Indian Health Service (IHS)
• Alaska Native Tribal Healthcare Consortium (ANTHC)

A formal, voluntary, inter-agency relationship
between the DoD, DoT, IHS and VA working together
by the sharing of each others resources,
talents, and experience to improve patient care
throughout the state of Alaska
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Developing Large Scale, Multi-Agency,
Multiple-Provider Type Telehealth Solutions for
Alaska
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• Large Scale
• 248 Sites
• 586,412 square miles
• Multi-Agency
• 41 Autonomous Organizations
• Native/Tribal, Military, Veterans, State of AK
• 3 Federal Agencies
• Multi-Provider
• Community Health Aide / Practitioners (CHA/P)
• Nurse, ANP, PA
• MD
• Specialist

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Why Alaska needs telemedicine

• 1st in land mass
• 47th in road miles
• 75 Alaskan communities unconnected by a road to
  a hospital. 25 of these have no airport.
• 48th in doctors to residents ratio
• Vast majority 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.

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Alaskas Experience

• Barrow - early 80s
• NSHC - CHAIN (Community Health Aide Information
  Network)
• Barrow - mid 90s - DDHC
• Public Health Nursing
• NLM - (ATTP - Alaska Telemedicine Testbed
  Project) - Installed in 26 village clinic, 4
  regional hospitals. Over 3,000 consults in 2
  years.
• AFHCAN - Begin installation 9/2000.

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Population
Alaska State Population 626,932
DoD/DoT 75,000 VA
75,000 IHS/Tribal
115,000 Total Federal/ 265,000 Tribal
Population
Note Total Federal/Tribal Population includes
both dual and triple beneficiaries
2000 Census Figures
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Governance

• AFHCP. Strategic relationships and MOA/MOUs
  between Federal partners existed before Federal
  funding was sought for a 4 year strategic plan.
• ANTHC. A managing partner was established in
  the original strategic plan.
• AFHCAN. Governance was established (in bylaws)
  through Boards in that plan.
• ORGANIZATIONS. Input was achieved through
  Committees and a Master Operating Plan.
• STATE OF ALASKA. Input was achieved through
  formation of the Alaska Telehealth Advisory
  Council (ATAC).

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OrganizationalRelationships
APO
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Master Operating Plan
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Referral Patterns
ANMC (Specialist)
Elm. AFB (Specialist)
AFHCP
Region (MD)
USCG (MD)
RMT
PRIVATE (Non-Federal)
Village (CHA)
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Village Clinic(Noatak)

• One of 184 Village Health Clinics
• 600 ft2
• 0 beds
• 4 CHPs

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Maniilaq Health Center(Kotzebue)

• 1 of 7 Bush Hospitals
• Opened in 1995
• 80,000 ft2
• 17 beds
• 8 physicians, 2 PA, 1 NP

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Single Organization
Maniilaq Health Center
Noatak Health Clinic
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Alaska Native Medical Center (Anchorage)

• Only Tertiary Care IHS facility in Alaska
• Opened in 1998
• 380,000 ft2
• 150 beds
• 89 physician staff

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Multi-Organizational SF
Maniilaq Health Center
Noatak Health Clinic
Alaska Native Medical Center (ANMC)
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AFHCAN Sites
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Funding

• AFHCP. All Federal funding was collocated to
  managing partner (ANTHC) and the distributed
  according to master plan.
• Equipment Funds. Equipment funds were calculated
  for each site according to staffing levels (CHA,
  NP, MD) and workload. Ownership of equipment was
  transferred to each organziation upon deployment.
• Site Funds. 22 of all project funds were
  provided in cash to each organization to
  prepare for, and support, telemedicine.

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Lessons we learned - Deployment
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Lessons we learned - Support
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Universal Service Fund

• Rural Health Clinics qualify for subsidy
• Spurred development of regional WANs
  T11000/month vs. 12,000
• Increased interest in participation in AFHCAN
• Made broadband applications feasible in remote
  areas

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PLANNING
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What are your key organizational goals for
telehealth applications?Please rank in order of
importance to your organization

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

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Subregional Center
Initial Entry
Both Initial Secondary
Secondary Care
Secondary Tertiary Outsourced Care
Harborview ANMC Providence AK API Private
MD/Dental
(Limited Entry) Petersburg Wrangall Skagway Ketchi
kan
The SEARHC Clinical System
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Clinical Committee Focus on Primary Care

• Store and Forward applications
• Ear Disease
• Dermatology, Wound Management
• Cardiology

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Allow Plans to Change
Original plan
Deploy 40
Deploy 20
Support 20
Deploy 40
Oct. 1998 Oct. 1999 Oct. 2000
Oct. 2001 Oct. 2002
What actually happened
NLM Deployment
Start Deployment
Server to Server
Equipment Selection
200th Cart
Oct. 1998 Oct. 1999 Oct. 2000
Oct. 2001 Oct. 2002
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Simplify Design Process

• Provide basic system to all sites.
• Refine system based on user feedback
• Plan for future development to need maturing
  needs.

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Multiphase Project
FY00
FY01
FY02
Phase 1 - Most Sites
Design
Deploy
Support
Phase 2 - Most Sites
Design
Deploy
Support
Phase 2 - Some Sites
Design
Deploy
Support
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AFHCAN Cart

• AFHCAN has deployed almost 300 carts to over 200
  locations.
• The Cart has proven to be exceptionally robust,
  with minimal downtime and exceptional durability.
• These carts are the basis for many telehealth
  cases being created statewide.

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AFHCAN Software

• AFHCAN Software now supports a unique
  server-to-server capability, allowing multiple
  organizations to communicate in a secure and
  efficient manner.

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Alaska Federal Health Data SharingPlanned
Project Relationships
NPIRS/ ORYX
GCPR
Alpha 3/01-7/01 Beta 7/01-12/01
MFI
Adding lab meds
Integrator
existing planned possible
Phase III 2/02
Adding 10 yr data
CHCS
VISTA
CPRS ANMC 1/02-6/03, field start
9/03
CPRS
HIS
RPMS
Going to CHCSII
ANMC billing 6/00-10/00
PACS
T2P2
AFHCAN
Telehealth
Telerad
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Alaska Telehealth Advisory Council

• Statewide Technical Standards
• Security
• File Formats
• Cardiology

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MAINSTREAM
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Production Telemedicine

• AFHCAN was not envisioned as a research
  project.
• It was designed as a production telehealth
  environment to be part of the mainstream
  health care delivery, characterized by
• High Utilization
• Sustained by organizations
• Integrated into health care delivery

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UTILIZATION
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1) High Utilization

• Meet existing clinical needs
• Promote local staffing and champions
• Provide comprehensive services
• Design system for end users
• Mitigate staff turnovers
• Develop a communications strategy

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AFHCAN Case Numbers
(10/8/2003)
TOTAL Cases 13,737
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AFHCAN Equipment Usage
(Archived Real Cases)
TOTAL Archived Real Cases 10,094
Cases using the Digital Camera 4,255 (42)
Cases using the Video Otoscope 4,860 (48)
Cases using the Scanner 2,235 (22)
Cases using no equipment 337 (3)
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2002 vs 2003 Usage
For the 5 top organizations using AFHCAN, usage
doubled in 2003 compared to 2002. This is shown
graphically for the 22 week period covering April
to August in each year
Number of Cases
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Usage in 2003 doubled
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If you dont use it regularly, then you will
forget how to use it
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Education can reduce antibiotic usage

• In the region receiving the education campaign
  and video otoscope
• total number of antibiotic courses per person
  declines 31 ...
• and number of courses per clinic visit
  declined 33

Arctic Investigations Program, National Center
for Infectious Diseases Centers for Disease
Control and Prevention, Anchorage, Alaska.
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SUSTAIN
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2) Sustainability

• Deployment strategies to build local buy-in and
  support
• Promote local on-site support
• Continuing Support and Training
• Continue to grow and expand
• Meet disparate needs of organizations
• Show value to the organization
• Mitigate staff turnovers
• Support reimbursement efforts

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Kiana Clinic
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Types of Sites by Staffing
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Improve the quality of data

• GIGO (image quality is critical)
• Regular use (not intermittent)
• Software too difficult if you dont use it
  regularly, then you will forget how to use it
• Continuous quality control
• Ongoing training

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n 317
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Focus Tool
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Reimbursement

• It is better to have a permanent income than to
  be fascinating.
• Oscar Wilde

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Medicare Reimbursement
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Medicare Reimbursement
We are specifying that for Federal telemedicine
demonstration programs conducted in Alaska or
Hawaii, Medicare payment is permitted for
telehealth when asynchronous store and forward
technologies, in single or multimedia formats,
are used as a substitute for an interactive
telecommunications system.
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Alaska Medicaid Reimbursement for all EM and
Consultant code for both SF and Interactive
Telemedicine. ANMC is generating over 300 bills
for 3 months ENT work.
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Medicaid StudyDecreased Travel Cost Savings
Note For every 1 spent by Medicaid on
reimbursement, 4.41 is saved on travel costs.
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INTEGRATE
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3) Integrated Health Care Delivery

• Understand work flow issues
• Scaleable systems
• Reliable systems
• High performance

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AFHCAN Referrals
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(11 of 11)
(5 of 14)
(5 of 28)
(5 of 46)
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Workflow the Providers view
You have been sent an AFHCAN Telemedicine
case. User Stewart Ferguson Date 11/21/2001
163453 PM Case Selawik123 Srvr AFHCAN_DEV3 Pl
ease choose from the following URLs to view this
case Click on this link if you are on the
AFHCAN network http//afhcandev3/afhcan Click
on this link if you are on the ANMC
network http//10.225.39.90/afhcan
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Will SF software be regulated by the FDA?

• Software, Servers are Class 1 Medical Devices
• Carts are Class 2 Medical Devices
• Follow Rigorous Quality Systems approach.

www.fda.gov/cdrh/comp/guidance/938.html
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NEW APPS
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Explore new Applications

• Parallel services to save resources
• Voice-over-IP, Teleradiology, Telepharmacy, VtC,
  Remote access to HIS
• Triage
• Reverse consults
• Travel providers to end sites
• Explore new services

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Tympanostomy tube follow up study - Why?

• 350 sets of tubes placed by ANMC providers in FY
  01
• 1000 -1300 follow up appointments needed in 13
  month period
• Many of these patients from remote areas

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Can store and forward digital imaging replace in
person examination for tympanostomy tube follow
up?
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Many simple problems, such as tympanostomy tube
follow can be done with telemedicine without
asking the patient to leave their village.
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Improved Access to Care

• Traveling Audiologist Program

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AFHCAN Virtual ENT Clinic

• Sites 5
• Aniak, St. Marys, Pt. Hope, Hooper Bay, Buckland
• Patients 102
• Cost 8300

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Services Supplied
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Outcomes
Faster Access 47
Avoidance 42
Rx 23
Note Percentages may not add to 100 due to
multiple outcomes per case.
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NSHC Experience

• During 2001
• Referrals for ENT clinic backlogged 12-15 months
• 80-100 outstanding new referrals
• Since January 2002
• Referrals for ENT clinic backlogged 2-4 months
• 47 outstanding new referrals
• August 16th 2002
• Negative backlog open slots

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FUTURE
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Technology Adoption Life Cycle Store Forward
AFHCAN
In order to be adopted by a broader market,
AFHCAN needs to demonstrate the value of its
product as well as provide a suite of supporting
services necessary to a successful implementation

• Grants driven
• Evaluative
• Wiling to try

• Reimbursement
• Demonstrate the value
• Whole product solution
• More mature product
• Complete support and services

From
To
Market revenue
Current store forward market
User volume
Late majority (Conservatives)
Early majority (Pragmatists)
Laggards (Skeptics)
Major segment of users adopting the technology
due to proliferation of the usage e.g. Private
insurers, urban hospitals
Innovators (Enthusiasts)
Major segment of users adopting the technology
e.g. Rural clinics, correctional facilities,
Medicare, Medicaid
Early adopters (Visionaries)
Rest of the market
Develop the early stage technology e.g. ANTHC
Adopt the early stage technology quickly e.g.
Grantees, military
Source Crossing the Chasm Industry expert
interviews OAT Grantee interviews
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AFHCAN
AFHCAN Strengths
AFHCAN Weaknesses

• Highly-visible, recognized brand
• Dominates a niche
• User-friendly product
• Largest user base
• Respected organization
• Deep domain expertise

• High-cost compared to some
• Limited features
• Incomplete documentation on product and
  deployments
• Lacks support services
• Slow organizational process

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Rationalize Alaska Deployment Framework
AFHCAN
Are program economics in-line with mission-driven
priorities?
High
Requires funding manage costs
Clear winner
Mission Match/Valued By Site
Potential distraction that threatens larger
mission?
Improve utilization, monitor
Low
Low
High
Resource Requirements
Make true costs of serving each site transparent
to ensure that scarce resources are being used to
most effectively advance AFHCANs mission
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Key Drivers Commercial vs. Grant-Driven Programs
AFHCAN
Commercial Programs
Grant-Driven Programs

• Revenue-driven
• Prioritize high revenue targets
• Focus on customers with funding

• Mission-driven
• Revenue generation is one of multiple goals
• Serve customers without regard to ROI

• Spend in correlation to revenue and ROI prospects
• Positive ROI required
• Focus on efficiency
• Achieve economies of scale

• Spend in correlation to funding raised
• Breakeven is the target
• Less focus on efficiency
• Costs grow as program grows

• Obsession with customer support and service

To be commercially viable, AFHCAN would need to
transition from grant-driven to
commercially-minded business practices
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Next Steps
AFHCAN

• Full and accurate analysis of AFHCAN costs
• Are program economics in line with mission-driven
  priorities?
• How does value vary with case mix, patient
  population, clinician staffing, alternative
  modalities, travel costs, etc?
• Quantify benefits of store and forward
• Improved outcomes
• Travel avoidance
• Other benefits
• Prepare for non-AFHCAN pilots
• Develop systems and procedures for commercial
  relationship
• Plan out supporting business functions
• Complete software revisions

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SUCCESS
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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)? (n4091)
(Since Project began)
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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)? (n809)
(Since Dec 15th 2002)
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For this case, rate the following statement
Telemedicine will improve the QUALITY OF CARE for
this patient. (n483)
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For this case, rate the following statement
Telemedicine improved PATIENT SATISFACTION.
(n446)
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For this case, rate the following statement
The telemedicine system played a role in
EDUCATING THIS PATIENT. (n512)
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