Improving Access to Quality Health Care in Virginia Improving Access to Quality Health Care in Virginia

through Information and Communication Technology:through Information and Communication Technology:

A Strategic Plan for the Development of a A Strategic Plan for the Development of a Telehealth Infrastructure in the Telehealth Infrastructure in the

CommonwealthCommonwealth

May 25, 2006May 25, 2006

Legislative Guidance for VTN Legislative Guidance for VTN Strategic PlanStrategic Plan

““Improvements Needed in Current Telemedicine Initiatives and Opportunities to Improvements Needed in Current Telemedicine Initiatives and Opportunities to Enhance Access and Quality." Document No.28 (2003)Enhance Access and Quality." Document No.28 (2003) recommended: recommended:

““ that a comprehensive strategic planning process should that a comprehensive strategic planning process should be the first step ….be the first step …. to: to:

Implement a comprehensive and integrated statewide TM/TH infrastructure.

Establish collaborative systems to ensure interoperability among entities with authority and responsibility to process data and information.

Legislative GuidanceLegislative Guidance

The “Report of the Secretary of Technology: A Joint Study to Establish The “Report of the Secretary of Technology: A Joint Study to Establish Guidelines for Ensuring Compatibility among Telemedicine Equipment, House Guidelines for Ensuring Compatibility among Telemedicine Equipment, House Document No. 18, 2000” Recommendations included:Document No. 18, 2000” Recommendations included:

– develop guidelines that would ensure compatibility among develop guidelines that would ensure compatibility among telehealth equipment operated by state agencies and other telehealth equipment operated by state agencies and other affected entities;affected entities;

– ““catalog” telehealth projects or programs throughout the catalog” telehealth projects or programs throughout the Commonwealth;Commonwealth;

– Develop communication mechanism to facilitate dialog among Develop communication mechanism to facilitate dialog among practitioners of, and parties interested in, telehealth projects;practitioners of, and parties interested in, telehealth projects;

– establish and maintain a listing of existing technical standards in establish and maintain a listing of existing technical standards in telehealth telecommunications, telehealth telecommunications,

– determine telehealth functional standards, determine telehealth functional standards, – reduce redundant or overlapping telehealth effortsreduce redundant or overlapping telehealth efforts

What is Telemedicine?What is Telemedicine?

Telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve patients' health status

- American Telemedicine Association website

Examples include:

•Tele-radiology

•Tele-surgery

•Tele-pathology

What is Telehealth?What is Telehealth?

.. Telehealth encompasses a broader definition of remote healthcare that does not always involve clinical services. Telehealth services include a range of health care, health education, and public health related services facilitated by the use of video conferencing, imaging and and other communications technologies.

Examples:

•Home health monitoring

•Bio-surveillance

• Patient translation services

What Types of Technologies are What Types of Technologies are Used in Telehealth/Telemedicine?Used in Telehealth/Telemedicine?

Telephone, faxTelephone, fax Local PCs Local PCs Email and InternetEmail and Internet Store and forward of digital imagesStore and forward of digital images Real-time patient medical data and Real-time patient medical data and

image exchangeimage exchange IP based Videoconferencing & VoiceIP based Videoconferencing & Voice Fully integrated networks Fully integrated networks

Low Tech

HighTech

What are the Challenges What are the Challenges of Rural Telehealth?of Rural Telehealth?

The development of rural telecommunications is not The development of rural telecommunications is not profitable to large telecommunications companies, so profitable to large telecommunications companies, so the infrastructure can be inadequate and/or costly the infrastructure can be inadequate and/or costly

Rural areas frequently have difficulties “keeping up” Rural areas frequently have difficulties “keeping up” with the rapid advances in technologywith the rapid advances in technology

Rural areas often lack the technical manpower and Rural areas often lack the technical manpower and expertise to troubleshoot and provide technical expertise to troubleshoot and provide technical assistance and training in the use of new technologiesassistance and training in the use of new technologies

What are the Challenges for Urban What are the Challenges for Urban Telehealth?Telehealth?

Systemic health disparities are found in urban Virginia. Systemic health disparities are found in urban Virginia. The urban underserved populations share characteristics The urban underserved populations share characteristics with their rural counterparts.with their rural counterparts.These health disparities take place in the context of an These health disparities take place in the context of an overburdened and ineffectively used healthcare delivery overburdened and ineffectively used healthcare delivery infrastructure. infrastructure. The urban underserved, just as their rural counterparts are The urban underserved, just as their rural counterparts are the most likely to use hospital emergency rooms for the most likely to use hospital emergency rooms for primary care because they have no alternative.primary care because they have no alternative.long-term investments in linking their medical facilities to a long-term investments in linking their medical facilities to a telecommunications infrastructure designed to address telecommunications infrastructure designed to address some of the health disparity challenges.some of the health disparity challenges.

The Virginia Telehealth Network (VTN)The Virginia Telehealth Network (VTN)

Began in November 2002 (under the Began in November 2002 (under the auspices of the Virginia Department of auspices of the Virginia Department of Health Office of Health Policy) as an Health Office of Health Policy) as an informal gathering of over 20 individuals informal gathering of over 20 individuals representing 14 private and public representing 14 private and public agencies/organizations who were agencies/organizations who were identified as key stakeholders involved in identified as key stakeholders involved in telehealth/telemedicine in Virginia.telehealth/telemedicine in Virginia.

Is now comprised of over 80 individuals Is now comprised of over 80 individuals representing 50 public and private representing 50 public and private agencies/organizationsagencies/organizations

Establishing the BaselineEstablishing the Baseline

During 2003 - 2004, the VTN Infrastructure Work Group (IWG) designed a site survey to capture information about:

Current telehealth infrastructure and capacity Future (next 36 months) plans for expansion of telehealth activities

VTN ConsensusVTN ConsensusBased on the findings of the site survey a white paper was developed by the VTN IWG recommending the development of an integrated statewide telehealth network infrastructure and organization designed to meet the present and future needs of all VTN members

The white paper was presented to approximately 100 participants who took part in the VTN Consensus Conference held in Natural Bridge, Virginia in May 2005.

In September 2005, a Strategic Plan Task Force was formed and charged with developing a plan to establish a statewide telehealth communications infrastructure

Snapshot of Telehealth Sites Snapshot of Telehealth Sites (December 2003)(December 2003)

Pound

Norfolk

WiseCedar Bluffs

Abington

Wytheville

Coving-ton

Blacksburg

MartinsvilleSouth Boston

LynchburgFarmville

Williamsburg

Newport News

Portsmouth

Petersburg

Richmond

Fredericksburg

Alexandria

Culpepper

Leesburg

Winchester

Fairfax

Harrisonburg

Charlottesville

Staunton

Pennington Gap

Big StoneGap

Norton

Clintwood

Gate City

Grundy

Vansant

Tazewell

Saltville

Dungannon

Konnarock

St. Paul

Marion

Bland

Bastion

Pulaski(2)

Salem

Pearisburg

BlacksvilleLebanon

Radford

Christiansburg

Floyd

StuartGalax

Hillsville

Clifton Forge

Hot Springs

Monterey

Low Moor

New Castle

Laurel Fork

Craigsville

Danville

Troy

Madison Heights

Goochland

Powhatan

Dillwyn

Blackstone

BoydtonCatawba

Warrenton

Manassas

Mitchells

Burkeville

Bowling Green

Colonial Beach

Jarratt

Dahlgren

ArlingtonFalls Church

Warsaw

AylettGlen AllenAshland

Tappahannock

St Stephens Church

Chesapeake

Heathsville

Suffolk

Callao

Hayes

Cheriton

Accomack

Franktown

Hampton

Virginia Beach

KilmarnockSaluda

Charles City

Vinton

Chesterfield

MontrossOlney

HartfieldLancaster

Nassawadox

(17)

(2) (2)

(2)

(2)(3)

(2)

(4)

(3) 2-H

(2)

Belle Haven

Roanoke

Bristol

Front Royal

(2)

(11)(3)

(2)

Woodstock

Lexington

Newport News

U.V.A.

Community Service Board

V.D.H.

D.O.C.

RAHEC

EVTN

VA Dept. of Mental Health (VDMHMRSAS)

VCU.

VT/VCOM

X= hub

= point of presence (POP)

XX

VCU VDH

UVA

Dept. of Corrections

However…Networks are IsolatedHowever…Networks are Isolated

VT/VCOM

VDMHMRSAS/CSB

HospitalsOTHERS

The Birth of a VisionThe Birth of a Vision

VCUVDH

UVA

Dept. of Corrections

Virginia Telehealth Network

Provider offices

HospitalsHome health

patients

Other Networks

VT/VCOM

VDMHMRSAS/CSB

EMS-Satellite

Geriatric facilities

VTN GoalVTN Goal

“ “To increase access to specialty care, To increase access to specialty care, ability to receive remote continuing ability to receive remote continuing education, reduced professional isolation, education, reduced professional isolation, pooled costs to drive down connectivity pooled costs to drive down connectivity charges”charges”

VTN 2006VTN 2006The Strategic Plan recommends development of a dedicated telehealth InfrastructureThe Strategic Plan recommends development of a dedicated telehealth Infrastructurenetwork, and organization – The Virginia Telehealth Network (VTN). network, and organization – The Virginia Telehealth Network (VTN).

– Note: VTN is not a telecommunications company and will not deploy new Note: VTN is not a telecommunications company and will not deploy new fiber. VTN will supply IP based MPLS services. VTN will utilize existing fiber. VTN will supply IP based MPLS services. VTN will utilize existing telecommunications network facilities and will act as a “customer” for telecommunications network facilities and will act as a “customer” for proposed rural broadband initiativesproposed rural broadband initiatives..

VTN will be available to all public and private healthcare related organizations, as VTN will be available to all public and private healthcare related organizations, as well as individuals. VTN will ensure that all communities within Virginia will have the well as individuals. VTN will ensure that all communities within Virginia will have the ability to access telehealth services via a broad range of access methods, from high ability to access telehealth services via a broad range of access methods, from high bandwidth to dial-up modems. bandwidth to dial-up modems.

VTN will provide a flexible, scalable, manageable, secure, and cost effective network VTN will provide a flexible, scalable, manageable, secure, and cost effective network infrastructure capable of linking healthcare providers and patients within Virginia, as infrastructure capable of linking healthcare providers and patients within Virginia, as well as nationally and internationally to ensure that all Virginians have access to well as nationally and internationally to ensure that all Virginians have access to World class healthcare . World class healthcare .

VTN will generates service revenues sufficient to ensure on going financial VTN will generates service revenues sufficient to ensure on going financial sustainability without the need for legislative subsidy after the initial “seed funding.” sustainability without the need for legislative subsidy after the initial “seed funding.”

Health And Human ResourcesHealth And Human ResourcesFY 07-08FY 07-08 Department Of HealthDepartment Of Health$840,203; $1,294,853 GF$840,203; $1,294,853 GF

GA appropriation defrays initial VTN GA appropriation defrays initial VTN subscriber costs for rural locations. This subscriber costs for rural locations. This includes VTN services such as:includes VTN services such as:– Access Access – Video bridgingVideo bridging– Equipment rental, install, maintenance and Equipment rental, install, maintenance and

trainingtraining– USF cost recovery assistanceUSF cost recovery assistance

VTN Network Design & VTN Network Design & Business CaseBusiness Case

VTN BenefitsVTN BenefitsVTN provides cost-savings for medical facilities and healthcare providers.

VTN provides immediate access to 24/7 technical assistance for interconnectivity problems that have in the past created obstacles to the adoption of telehealth services for primary care, home health monitoring, treatment and follow-up.

VTN provides a travel alternative for patients and their families who must often travel great distances at their own expense to receive appropriate healthcare.

VTN provides a means for patients throughout Virginia to enjoy the continuity of care that can be delivered through telehealth applications which rely on a broadband infrastructure.

VTN Benefits (con’t)VTN Benefits (con’t)

VTN provides the only comprehensive means in Virginia to ensure full-scale interactive broadcast messaging to all medical and social services professionals in times of national threats and disease outbreaks.

VTN provides the necessary infrastructure for patient health record exchanges.

VTN positions the Commonwealth to become a national leader in the delivery of TH/TM services.

OTHER IP HEALTH

NETWORKS

VTN SUB NETWORK

VTN SUB NETWORK

Remote Sites

Remote Sites

Remote Sites

Remote Sites

Remote Sites

Remote Sites

VTN BACKBONEVIRGINIA TELEHEALTH NETWORK

VTN NETWORK

Other IP Networks

Public InternetNetwork

Local Carrier

NETWORK VTAP

NetworkRouter

NNI type of Connection

WiFi

WiMAX

Dial lines toLocal Carrier

Firewell

Direct Connection

TO BACKBONE

Remote Sites

Remote Sites

Remote Sites

Remote Sites

Remote Sites

Access to ALLAccess to ALL

Remote Sites

Remote Sites

Remote Sites

VTAP (UVA)

VTAP – Virginia TeleHealth Access PointVTSAP – Virginia TeleHealth Secondary Access Point

VTSAP

VTSAP

VTSAP VTSAP VTSAP

Remote SitesRemote Sites

Remote Sites

VIRGINIA TELEHEALTH

NETWORK

Remote Sites Remote Sites

OSC3 BackboneOSC3 Backbone

OSC3 Backbone

DS3 BackboneDS3 Backbone

VTAP (VCU)

VTAP (?)

DS3 Backbone

VTN Phase I & II Physical LayoutVTN Phase I & II Physical Layout

VTN Example of a Virtual (VPN) LayoutVTN Example of a Virtual (VPN) Layout

VPNRegion 1

VPNRegion 4

Health Center Health Center

Tier 1

VPNRegion 2 VPN

Region 3

Tier 2

3

This example shows a network that is composed of 4 VPNs. Region 1 and Region 2 need their users to talk to region 4. Region 3 is isolated from region 4. However, regions can be re-configured as needed.

Business Case AssumptionsBusiness Case Assumptions

User fees based on access speed and services used:User fees based on access speed and services used:– Video conferencingVideo conferencing– Web meetingWeb meeting– Equipment rentalEquipment rental– Video bridgingVideo bridging– USF cost recovery assistanceUSF cost recovery assistance– Central scheduler softwareCentral scheduler software

At 4 year 300 remote sites and 40 large usersAt 4 year 300 remote sites and 40 large users– Remote site: Rural or free clinics or home TM (through a Remote site: Rural or free clinics or home TM (through a

provider). Future, remote sites could include nursing homes, provider). Future, remote sites could include nursing homes, area agency on aging sites, assisted living facilities etc.area agency on aging sites, assisted living facilities etc.

– Large users: Universities, tertiary and secondary health systemsLarge users: Universities, tertiary and secondary health systems

VTN Users' ForecastVTN Users' Forecast

0

50

100

150

200

250

300

350

Yr 1 Yr 2 Yr 3 Yr 4

Large Sites

Remote Sites

Large number of remote sites assumes increasing adoption of home telemedicine

VTN Capacity ForecastVTN Capacity Forecast

0

100

200

300

400

500

600

700

800

Yr 1 Yr 2 Yr 3 Yr 4

# of Customers

Bandwidth (Mbps)

VTN Business Case VTN Business Case

$0

$500,000

$1,000,000

$1,500,000

$2,000,000

$2,500,000

$3,000,000

$3,500,000

$4,000,000

$4,500,000

YR 1 YR 2 YR 3 YR 4

Seed MoneyLoans/GrantsVTN Revenues

VTN Revenue ForecastVTN Revenue Forecast

Access Services

Video Services

Web Meeting

Equipment Lease

Home Telemedicine

Access Services

Video Services

Web Meeting

Equipment Lease

HomeTememedicine

Acces Services

Video Services

Web Meeting

Equipment Lease

HomeTeleMedicine

Access Services

Video Services

Web Meeting

Equipment Lease

Home TeleMedicine

Year 1 Total $442K Year 2 Total $1,246K

Year 3 Total $2,307K Year 4 Total $4,002K

Next StepsNext Steps

Next StepNext Step

Appropriate state monies to (a) provide operational Appropriate state monies to (a) provide operational expenses for VTN to implement the two pilot expenses for VTN to implement the two pilot projects included in the Strategic Plan in FY07 projects included in the Strategic Plan in FY07 and FY08, and (b) leverage an estimated Rural and FY08, and (b) leverage an estimated Rural Utility Services (RUS) loan/grant of $1.8 Utility Services (RUS) loan/grant of $1.8 million.million.

RecommendRecommend state appropriation of $840,203 for state appropriation of $840,203 for Year 1, and $1,294,853 for Year 2 for VTN start-up Year 1, and $1,294,853 for Year 2 for VTN start-up and operations. Total appropriation: $2,135,056.and operations. Total appropriation: $2,135,056.

Next StepNext Step

Establish a nonprofit corporation to Establish a nonprofit corporation to implement the Strategic Plan for the implement the Strategic Plan for the Virginia Telehealth Network Infrastructure.Virginia Telehealth Network Infrastructure.

RecommendRecommend VTN governance begins with VTN governance begins with volunteer representation by VTN end-users and volunteer representation by VTN end-users and interested parties; and through VDH sponsorship interested parties; and through VDH sponsorship transition VTN to a representative organization of transition VTN to a representative organization of end-users within 12 months.end-users within 12 months.

Next StepNext Step

Establish collaborative relationships with major stakeholders Establish collaborative relationships with major stakeholders in Virginiain Virginia

Investigate the possibility of establishing VPOPs in key Investigate the possibility of establishing VPOPs in key locations in Virginia (i.e. UVA , VCU ,VCOM, EVMS etc.). locations in Virginia (i.e. UVA , VCU ,VCOM, EVMS etc.). Including:Including:

VTN Network equipment on siteVTN Network equipment on site contracting for university technical servicescontracting for university technical services VTN lease of space and electric powerVTN lease of space and electric power

The Strategic Plan Task ForceThe Strategic Plan Task Force

Michael Aisenberg – Liberty Alliance/Verisign

Ed Bostick – Northern Neck Middle Peninsula Telehealth Consortium

Peter Buccellato – Knowledge Providers Group

Rebecca Davis – Virginia Rural Health Association

Steve Gillis – Telehealth Solutions Group

David Heise – Telehealth Solutions Group/MCI

Jay Sanders – The Global Telemedicine Group