Telemedicine in the Alaska Tribal Health System

1. Telemedicine in the Alaska Tribal Health System Sarah Freeman, PharmD Telehealth Program Development Director AFHCAN Alaska Native Tribal Health Consortium

2. Alaska Tribal Health System Voluntary affiliation of 30 Alaskan tribes and tribal organizations providing health services to Alaska Natives/American Indians (7,000 employees) Each is autonomous and serves a specific geographical area

3. Alaska Native Medical Center The Alaska Native Tribal Health Consortium and Southcentral Foundation jointly own and manage ANMC under the terms of Public Law 105-83. These parent organizations have established a Joint Operating Board to ensure unified operation of health services provided by the Medical Center. • Jointly managed by ANTHC (statewide) and Southcentral Foundation (regional) • ANTHC provides specialty services • SCF provides primary care services • Primary hospital services for Alaska Natives from Anchorage and rural Southcentral Alaska • Tertiary/specialty hospital for all regions (entire state)

4. Medical Care Service Levels • Alaska Native Medical Center tertiary care • Referrals to private medical providers and other states for complex care • 6 regional hospitals • 4 multi-physician health centers • 25 subregional mid-level care centers • 180 small community primary care centers

5. 24% of all rural Native homes do not have adequate sanitation

6. Village-Based Medical Services Average Alaska village  350 Residents • 180 Small Village Health Centers • 550 Community Health Aides/Practitioners • 125 Behavioral Health Aides • 20 Dental Health Aides/ 12 Therapists • 100 Home health/personal care attendants

7. “Telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve patients' health status.”“… "telehealth" .. is often used to encompass a broader definition of remote healthcare that does not always involve clinical services. “ ATA Defining Telemedicine http://www.americantelemed.org/news/definition.html

8. Telemedicine Carts 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

9. Case originated…

10. …Case received, reviewed, and recommendation made

11. AFHCAN Telehealth Program Installed Customer base includes: • Alaska: 248 sites, 44 organizations • 66 operational systems in 2011 • 1,564 providers in 2012 • 22,353 patients in 2012 (16% of AN pop) • Primarily Store and Forward • Managed by ANTHC • 28 Staff • 12 year Operational History • 35,000 cases/year • 199,000 Cases (ATHS)

12. AFHCAN - by the numbers … 2013 Since 2001 36,229 22,982 1,686 914 Cases created Patients served Providers involved Providers creating ATHS (Alaska Tribal Health System) (1/1/2000 to 3/31/2014) 199,562 82,274 3,953 2,335

13. Role of Telemedicine • Store and Forward • 3% of encounters • Primary Care (75%) • Specialty Care (25%) • Triage / Planning • Discharge Planning • Esoteric : Abuse … • Videoteleconference • Cardiology • Oncology • Pediatrics • HIV/EIS • Endocrinology • Pulmonology • Breast Cancer Screening • Behavioral Health

14. Estimated Travel $ Saved Across ATHS

15. ATHS (Alaska Tribal Health System) (1/1/2000 to 9/30/2013)

16. Telehealth Impact on Extended Waiting Times (> 4 months) Data courtesy of Phil Hofstetter

17. Pre-Operative Planning for Ear Surgery Using Store-and-Forward TelemedicineJohn Kokesh M.D., A. Stewart Ferguson Ph.D., Chris Patricoski M.D. The average difference was not statistically different between the two groups: 32 minutes for the telemedicine evaluation group and 35 minutes for the in-person 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)

18. Post-surgical follow-up is difficult for patients from remote settings. Telehealth provides ability to monitor and followup. Post-Operative 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.

19. Integrated Data Systems EHR, HIE, Telehealthsystems, mobile apps Managed Video Services High Availability 7/24 Scheduling Bandwidth Mgmt Addressing End Point Mgmt Telemedicine Expansion • Tele-emergent care • Emergency Department • Trauma • Disaster • Suicide/Crisis Intervention • eICU, ePICU • PTSD and TBI services • Care Conferencing/Discharge Planning • Direct to Consumer Healthcare • Statewide Pediatric Specialty Services

20. Telepharmacy Programs There are no local pharmacies in the remote areas Automating Dispensing Units in 29 clinics operated by 9 Tribal Health Organizations Access to Pharmacist in “real time” Without telepharmacy, residents in remote areas commonly experience delays in receiving mailed supplies of medication due to weather, reduced flight service secondary to high fuel costs, etc.

21. Teleradiology Programs Teleradiology and digital imaging requires a wider bandwidth for effective transfer of images. The teleradiologyproject at ANMC began in 1998 with significant impact • Before project: 7-9 day turnaround time on reads • Today: instantaneousreports for STAT reads 24 hour reads for routine exams

22. Community Health Aide Program The Alaska Community Health Aide/Practitioner Manual (CHAM) is used as a guideline for every patient visit and follow-up with the physician.

23. Mobile Devices in ATHS Health Care EDUCATION CHA/P Program – eCHAM CONSULTATION Telehealth – tConsult eVISITSVideoconferencing – Vidyo DATA Cerner – Touch

26. Medical Costs for Children What are the characteristics of this 20% ?

27. Children 0-1 Years

29. A Statewide Comprehensive Virtual Medical Home for Children with Complex Medical Conditions • Home environment assessments / upgrades • Videoconferencing • To Home (Terra project) • To Clinic (eCHAM project) • Statewide (Vidyo project) • Intensive care management • Statewide Care Management (HIE) • Coordinated visits and access across EHRs • New Payment models (SOA Medicaid) • Partnership with SOA, Subspecialists, UW, …

30. Thank you!!