Reaching Our Most Remote Sites The Alaska Experience

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Reaching Our Most Remote SitesThe Alaska
Experience
A. Stewart Ferguson, Ph.D. Director,
AFHCAN Chris Patricoski, MD Clinical Director,
AFHCAN Alaska Native Tribal Health
Consortium Anchorage, AK, USA
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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 states combined.

• 47th in road miles
• 75 Alaskan communities unconnected by a road to
  a hospital.
• 25 of these have no airport.
• Population density is 1.1 persons/mile2
• 70 times smaller than the national average.
• If Manhattan had this population density, there
  would be just two people living there.
• Outside of the three largest communities in
  Alaska, density drops to about 0.5 persons/mile2

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Health Professional Shortage Areas in Alaska

• Most of Alaska is designated with some form of
  HPSA status.
• Statewide underserved population of 370,088
• 59 of the states residents
• This is probably understated

• 23 of 27 Boroughs/Census Areas are either
• Whole or part Medically Underserved
  Area/Population (MUA/P) or
• Governor-designated Medically Underserved
  Population (MUP)

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Health Care Delivery

• No managed care in Alaska
• Federal system
• Military (US Army, US Air Force)
• USCG
• Veterans Affairs
• Alaska Tribal Health System (ATHS)
• Public Health
• Community Health Centers
• Private Providers

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Telemedicine is the use of telecommunications
technology for medical diagnostics, monitoring,
and therapeutic purposes when distance and/or
time separates the participants.

• Telemedicine for the Medicare Population Update
• Evidence Report/Technology Assessment No. 131,
• Agency for Healthcare Research and Quality
  (AQRQ), 2006.

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AFHCAN Telehealth

• 8 years operational history
• RD Telehealth System
• 10,000 cases / year
• Manufacturing of Medical Devices
• Whole Product Solution
• Design ? Installation ? Training ? Support ?
  Marketing
• Installed Customer base includes
• 248 sites, 44 organizations
• 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)

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Who is using Telemedicine

• In FY 2005, 65 of 431 Indian health facilities
  that reported data sited clinical telemedicine
  activity
• Experience with over 30 clinical applications

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ALASKAs 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
• 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.
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IHS Appropriations Per Capita Compared to Other
Federal Health Expenditure Benchmarks
January 2006
------- Growth Forecast Through 2005
IHS
l
Non-medical
IHS __ Medical
Last Published Data
498
2002
2002
1999
2003
2002
1999
See notes on reverse for data sources and
forecast assumptions.
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ATHS

• 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.

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Unemployment

• Alaskas unemployment rate in Feb 2004 was 8.9,
  one of the nations highest.
• The Bristol Bay and Yukon Kuskokwim areas have
  been labeled Economic Disaster Areas for several
  consecutive years due to severly compromised
  fishing.

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Poverty Levels

• More than 25 of Alaskans are considered to be
  living below 200 of the poverty level.
• Nearly 35 of Alaskan students are identified as
  economically disadvantaged.
• The percentage of school age children from low
  income families soars to 80 in remote locations

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How can Telehealth reduce the cost of health care?

• Physicians 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)? (n8,657)
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Preventing Patient Travel
Cases Preventing Travel Per Week
Prevent Patient Travel
? 68
22 ?
No Effect
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Travel Savings

• Assumptions
• Round trip airfare is 300 to 900
• Patient may require guardian or parent to travel
• 10,000 annual telehealth cases
• 68 of cases prevent patient travel
• Savings are 2m to 12m annually
• Most likely in range of 3m to 9m
• Would grow with lodging and perdiem

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Causing Patient Travel
Cases Causing Travel Per Week
Cause Patient Travel
Telehealth CAUSES patient travel 8 of the time
(typ.) Usage of the ECG causes travel 12 of time.
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Medicaid StudyDecreased Travel Cost Savings
Note For every 1 spent by Medicaid on
reimbursement, 7.95 is saved on travel costs.
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Providing Care in the Patients Community
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Extending Care to the Village
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

• Pilot project providing audiological services at
  the village clinic

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Traveling AudiologistTravel Avoidance Cost
Savings
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Outcomes (n897)
About 73 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.
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Improving Access

• Greater Efficiency of Existing Resources

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What are your key organizational goals for
telehealth applications?
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Ear Disease in Alaska

• Ear disease represents the major presenting
  symptom in 10-15 percent of all Alaskan village
  encounters.
• In a 1982 survey of four villages, chronic otitis
  media with effusion (OME) occurred in 8.9 of
  persons under 20 years of age and 21 of children
  under 5 years of age.
• Among groups most affected by chronic supporative
  otitis media are the Inuits of Alaska (30 to
  46), Australian Aborigines (12 to 25) and
  certain Native American tribes such as the Navajo
  tribes (4 to 8).

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Less Waiting Time for Patients

• Nome
• ENT waiting time
• 6-9 months 2002
• 2-3 months 2003

The specialty clinic manager came to see me
this morning to indicate that there were four
open slots in ENT clinic for September. This
is the first time they were having a tough time
to fill those spots!! Speaks well of the
telemedicine. Philip Hofstetter Audiolog
ist, NSHC
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Less Waiting Time for Patients
Waiting time for a field clinic appointment
has gone from 4-5 months a year ago to 1-2 months
now. . Ive probably got 100 stories of patients
or parents who were pleased with the quicker,
easier access to ENT services they received
either through telemed or direct referral.
Mike Comerford Audiologist, Yukon
Kuskokwim Health Corporation

• Bethel
• ENT waiting time
• 5 months in 02
• 0-2 months in 03
• Each open slot created by telehealth provides an
  opportunity for non-telehealth patients to
  benefit from telehealth

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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.
• 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.

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Meeting Standards of Care

• Post-surgical follow-up 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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Cardiovascular Diseasein Alaska

• The second leading cause of death
• 850 persons will die this year
• For every homicide, there are approximately 20
  deaths due to CVD

• From ages 1 to 65, American Indian and Alaska
  Natives have higher mortality rates from Cardiac
  Disease compared with All-Race Rates by Age

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Telehealth and ECG

• The ECG is used in 10 of all Alaska telehealth
  cases
• 12 of these cases CAUSE patient travel.
• Only 8 of all telehealth cases cause patient
  travel.

Ultra-Portable Telehealth Technology Home Health
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For this case, rate the following statement
Telemedicine will improve the QUALITY OF CARE for
this patient. (n1,681)
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Increasing Efficiency

• ANMC ENT Department
• 1200-1500 telemedicine encounters
• These are patients encounters that would not have
  happened.
• Decrease Opportunity Costs
• Equivalent to 13 ENT specialty clinics lasting 4
  days
• ENT physician cost savings 63,000
• Additional Revenue 80,000
• With no additional ENT staffing needed to process
  cases

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INDIAN HEALTH SERVICE THealth Centers of
Excellence
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Hiring Providers

• 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
• Alaskas 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.

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For this case, rate the following statement
Telemedicine makes my JOB MORE FUN. (n1,897)
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.
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Evaluation Responses

• 64 of cases played a role in educating the
  patient. (N1,713)
• 77 of cases helped make the provider's job more
  fun. (N1,897)
• 79 of cases were rated as improving patient
  satisfaction. (N1,615)
• 86 of cases were rated as improving the quality
  of care for the patient. (N1,681)
• 89 of cases helped providers communicate with a
  doctor. (N1,606)

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IHS-AFHCAN Collaboration

• National Telehealth Infrastructure
• Offer a secure enterprise solution for
  telemedicine across Indian health

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Strong Foundation

• Build from existing successes

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Integrated Systems of Care

• Focus on a standards-based enterprise
  architecture that includes
• Images and telehealth information with the IHS
  Electronic Health Record
• Extends systems of care via home telehealth and
  other mobile activities

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Conclusions

• Telehealth significantly improves ACCESS TO CARE
  and decreases COST OF CARE.
• Telehealth will become a larger issue in response
  to the drivers of budget limitations and rising
  costs.
• Telehealth requires continued and expanded
  support at the Federal level
• These is a metamorphosis within telehealth where
  systems now share, merge, aggregate, and partner.

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Medically Underserved Areas

• Alaska 27
• Hawaii 17
• Idaho 48 MUA
• Montana 63
• All or parts of Montanas 56 counties are
  Federally identified Health Professional Shortage
  Areas (HPSAs), Medically Underserved Areas
  (MUAs) or Dental Shortage Areas (DSAs)
• Oregon 66
• Utah 23
• 20 of Utahs counties are designated as Primary
  Care Health Professional Shortage Areas (HPSAs),
  25 are designated as Mental Health HPSAs, 21 are
  designated as Dental HPSAs.
• Washington 53
• Wyoming 14
• 18 of 23 Wyoming counties have HPSA designation
  all 23 counties designated mental health PSAs.

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Northwest Regional Telehealth Resource Center
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MISSION

• To promote a "best practices" approach to
  telehealth service delivery in AK, HI, ID, MT,
  OR, UT, WA, WY and Pacific Islands through
• Sharing information
• Leveraging existing resources
• Assisting program innovation and development

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Proposed Goals

• Enhanced capability for all telehealth programs
  through expertise sharing and organized
  assistance.
• Provide a mechanism for an effective investment
  of federal and state funds in telehealth
  programs
• Promote better health care delivery through
  increased access to care on a regional basis.
• Increase the awareness and exposure for
  telehealth as a viable tool for efficient
  delivery of health care.
• Improved communication and access between
  individual projects and national health care
  leadership.

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Thank You!
SFerguson_at_afhcan.org
AFHCAN, Alaska Native Tribal Health Consortium,
Anchorage, AK