VA Northwest Health Network Veteran Integrated Service Network (VISN) 20

1. VA Northwest Health Network Veteran Integrated Service Network (VISN) 20 Joseph L. Ronzio, DHSc, CPHIMS, SMHIMSS VA Northwest Health Network VISN Telehealth Coordinator Tracy Dekelboum, MSW Southern Oregon Rehabilitation Center and Clinics Facility Telehealth Coordinator

2. What is Telehealth? • The VHA Office of Telehealth Services states: Utilizingtelehealth services supports “providing the right care in the right place at the right time through the effective, cost-effective and appropriate use of health information and telecommunications technologies” • Utilizing Telehealth services: • Increases access to care for services not normally available at a facility; • Increases availability of and access to care for Veterans in rural locations; • Reduces travel expenses to other VA sites for care which is replaced by telehealth services; • Reduces non-VA expenses for specialty care

3. Clinical Video Telehealth (CVT) • A Process utilizing telehealth technologies to provide care and consultation between VA sites, VA sites and the home setting, and between VA and non-VA sites. This allows the patient to be examined or interviewed at a location different from the provider, via real-time interactive video images. • The VA utilizes a national video telecommunications infrastructure to support CVT.

5. VISN 20 CVT Services • Telemental Health • Pacemaker / ICD • Nutrition and Dietician • Move • Traumatic Brain Injury • Rehabilitation and Amputee • Diabetes • Hepatology • Pain Clinic

6. Store and Forward (S&F) • A process in which a trained imager or health technician takes digital images or captures digital data of a patients’ condition, downloads the images or data to VistA that are interpreted by a remote consulting provider.

7. VISN 20 S&F Services • For teledermatology conditions a standard point and shoot camera is utilized. • For teleretinal imaging a digital SLR camera is connected to a lens unit which can focus on and inside the eye. • Teleradiology • Epilepsy EEG diagnostics

8. Home Telehealth (HT) • A process using Home Telehealth technologies to manage Veterans with chronic diseases at their home in order to improve clinical outcomes and access to care. This program supports and complements the care by our primary care teams.

9. VISN 20 HT Services • Diabetes • Congestive Heart Failure (CHF) • Cardiac Care • Hypertension • Mental Health Issues: Depression & PTSD • Obesity (Tele-MOVE)

10. VISN 20 • Description of Challenges of our Network • Largest amount of land of any VA Network • Very rural locations (Alaska, Southern & Eastern Oregon) • Only two major tertiary care facilities • High non-VA care and beneficiary travel costs • Benefits of our Network • VA Electronic Health Record – CPRS • Frequent communication amongst sites • Decent collaboration and support amongst sites • Pre-existing telehealth programs Telehealth is a natural addition to the healthcare provided

11. VISN 20’s Telehealth Network • Established a standardized VISN-wide Business Structure • Designation of Facility Telehealth Coordinators (FTHCs) to oversee each facility’s telehealth activities • Implementation and use of Telehealth Clinical Technicians (TCTs) to provide technical support, training, and clinical support • Implementation of VISN wide and facility based telehealth committees • Establishment of VISN Telehealth Technical Committee comprised of Office of Information and Technology staff, Bio Medical Engineering staff, and FTHCs

12. VISN 20’s Telehealth Network • Establishment of standardized documents proposing and facilitating all telehealth programs • Business plan • Telehealth Service Agreement (TSA’s) • Standard Operating Procedure (SOP’s) • Establishment of standardized equipment use and purchase amongst all sites of care

13. Developing a Network WideTelehealth Program • Rural location benefits greatly from telehealth Services • Description of demographics/idiosyncrasies of locations • Developing a Telehealth program requires a mix of aggressiveness and hand holding • Share transition of technology to make aware of actual use of technology • What is in it for them? • Workload credit • Increase in Patient Access to care • Ability to have more meaningful communication with patients • Ability to be in same room as other provider provides care

14. Developing a Facility Program:SORCC Telehealth Program • The Southern Oregon Rehabilitation Center & Clinics (SORCC): • residential facility w/approximately 450 beds • provides residential and outpatient mental health and substance use rehabilitation with primary care and limited specialty care availability • approximately 16,000 unique Veterans per year • Rural Location: • Medford, our main city is considered by VA to be urban • All other areas are rural and highly rural • Treatment Sites: One Community Based Outpatient Clinic (CBOC) and one Outreach Clinic

15. Developing a Facility Program:SORCC Telehealth Program cont’d • Due to limited clinical services, telehealth is primarily “done unto us” • Will expand SORCC services to our CBOC and Outreach Clinic in 2012

16. SORCC Programs • Clinical Video Telehealth • TelementalHealth • Tele Pain Management • Veterans Court • Home Telehealth • Store & Forward • Teleretinal Imaging • Teledermatology • Implement in 2012 • Arrhythmia • Pace Maker • Home Based TMH & PC • Expansion of Diabetes Health Clinic • Pre & Post Op Clinic

17. Involvement in a Network Telehealth Program • Networking opportunity and support amongst FTHCs • Frequent communication • Bi-weekly organized call • As needed communication • Education on “everything telehealth” by VISN Telehealth Coordinator and Director • Diversity in skill amongst FTHCs – the whole is greater than the sum of its parts • Ability to provide “the right care in the right place, at the right time” • Providing care as “One VA”

18. Experience - CVT • FY 11 Data • 5,747 patient encounters • 2,296 unique patients • 1,788,502 patient miles of travel saved • FY10 Data • 3,358 patient encounters • 2,391 unique patients • Just over 1M patient miles of travel saved • FY09 Data • 2,013 patient encounters • 1,690 unique patients

19. Experience – Home Based CVT • First VA to launch a successful Home Based Clinical Video Telehealth for Mental Health • Patient Centered • Saved over 20,000 miles of patient travel with just over 50 patients in 1.5 years • Higher patient satisfaction than clinic based telehealth services • Significantly lower patient now show rates • Less than .5% • Traditional mental health care is 12% to 24% • Clinic based telemental health is 8% to 18%

20. Experience – CVT • Provider Empowered • Telework is possible • Patients are less stressed upon arrival • Patients with a history of violence

21. Experience - S&F • FY 11 Data • 14,596 patient encounters • FY10 Data • 9,950 patient encounters • FY09 Data • 8,438 patient encounters

22. Experience - S&F • S&F for providers is a multiplier • 1 hour face to face encounters = 5 to 15 minute image reads • There is a need for training to be accomplished by imagers • There is a need to constantly monitor imager quality • Patient follow-up can be extremely complicated • Especially if you are imaging multiple body locations with suspected problems

23. Benefits/Satisfaction/Challenges • Benefits • Increase in Patient Access to care • Ability to have more meaningful communication with patients • Ability to be in same room as other provider provides care • Workload credit – telehealth is considered a face-to-face appointment • Satisfaction • High Veteran satisfaction both in communication and in elimination of lengthy travel • Provider satisfaction in communication success and ability to be present during the Veterans’ session with non-SORCC providers, skill building • Challenges • Obtaining Clinical Champions to lead efforts • Obtaining buy-in for participation • Scheduling provider and room time • Coordination with providing sites

24. Things to Never Forget • Assure purchase of sufficient bandwidth as there never seems to be enough • Assure all equipment is compatible and standardized where possible throughout the network • Develop a systematic approach for Gaining Buy-in • Benefit to patient access • Benefit to providers • Get to play with cool shiny toys  • Importance of Clinical Champions • To lead innovation • To support followers

25. Questions