“The Future is Here – A Regional Health Information Technology Summit”

Friday, June 15th 10:30 am – 11:55 am

Regional Indian Health Service Projects and Programs

Christopher Lamer, PharmD, BCPS, CDE

on behalf of Mark Carroll, MD

IHS Telehealth Program Director

Indian Health ServiceMission, Goal, and Foundation

• The Mission, in partnership with American Indian and Alaska Native people, is to raise their physical, mental, social and spiritual health to the highest level.

• The Goal is to ensure that comprehensive, culturally acceptable personal and public health services are available and accessible to all American Indian and Alaska Native people.

• The Foundation is to uphold the Federal Government’s obligation to promote healthy American Indian and Alaska Native people, communities and cultures, and to honor and protect the inherent sovereign rights of Tribes.

IHS Overview

• Provides a comprehensive health service delivery system for approximately 1.9 million of 3.3 million American Indians and Alaska Natives.

• Serves members of 561 federally recognized Tribes in 35 states.

• FY 2007 appropriation is approximately $3.2 billion.

• Indian Health Service total staff consists of about 15,850 employees, which includes approximately 2,600 nurses, 930 physicians, 390 engineers, 500 pharmacists, 300 dentists, and 170 sanitarians

Partnership with Tribal Governments

• The Indian Self-Determination Act of 1975 includes an opportunity for Tribes to assume the responsibility of providing health care for their members, without lessening any Federal treaty obligation.

• Tribes now administer health care contracts and compacts with the IHS valued at over $1.5 billion. This represents approximately 54% of the IHS budget authority appropriation.

163 Service Units in 12 Areas Located in 35 States

Indian Health Care Systems

Source: IHS Regional Differences, 2000-2001

Hospitals Health Centers

Alaska Village Clinics

Health Stations

IHS 33 54 N/A 38

Tribal 15 229 162 116

The IHS also supports 34 Urban Clinics across the nation.

Rural Primary Care System – with some Urban Locations

Hospital

Ambulatory Center

60% of IHS hospitals and ambulatory centers are in remote areas

IHS Hospital System

• JCAHO/CMS Accredited

• Size varies: – 156 Beds - 6 Beds

• 59,000 Admissions per year (2006)

• 9,797,000 Outpatient visits per year (2006)

Community Oriented Programs

• Community oriented primary care

• Public health emphasis

• Traveling services in remote villages

• Community health representatives

• Village health aids

• Community & school health education

Traveling dental team visits remote villages in Alaska

80.4

76.3

66.0

64.1

59.6

57.1

45.7

39.7

38.7

16.8

0 20 40 60 80 100

Tuberculosis

Cervical Cancer

Infant Deaths

Maternal Deaths

Accidental

Homicide

Alcohol-Related

Cerebrovascular

Pneumonia & Influenza

Suicide

Percent Decrease in Mortality Rates(Adjusted for misreporting of AI/AN race on State death certificates.)

CY 2000-2002

Mortality Rates for Indian People Have Declined Since 1973

U.S. Ratio: AI/AN All Races AI/AN Rate Rate to U.S. 2001- 2003 2002 All Races

ALL CAUSES 1042.2 845.3 1.2 Tuberculosis 1.8 0.3 6.0 Alcoholism 43.6 6.7 6.5 Diabetes 75.2 25.4 3.0 Motor vehicle crashes 51.1 15.7 3.3 Unintentional Injuries 93.8 36.9 2.5 Homicide 12.7 6.1 2.1 Suicide 17.1 10.9 1.6 Cervical cancer 4.4 2.6 1.7 Infant deaths 1/ 9.8 7.0 1.4 Cerebrovascular diseases 54.7 56.2 1.0 1/ Infant deaths per 1,000 live births

NOTE: American Indian and Alaska Native (AI/AN) rates were adjusted to compensate for misreporting of AI/AN race on state death certificates. AI/AN rates are based on 2000 census with bridged-race categories developed by the Census Bureau and the National Center for Health Statistics. Jan. 2007

Mortality Rate Disparity Continues American Indians and Alaska Natives in the IHS Service Area 2001-2003(Age-adjusted mortality rates per 100,000 population)

Prevalence of Diagnosed Diabetes:AI/ANs Compared to U.S. Pop

Source: IHS Program Statistics and National Diabetes Surveillance System.

0

5

10

15

20

1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004Year

Percent

AIAN

US

Per Capita Expenditures Trend:IHS Compared to US Average

$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

$3,500

$4,000

$4,500

$5,000

$5,500

$6,000

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

IHS Per Capita Expenditure

US Per Capita Expenditure

*for personal health care services

Summary of the IHS

• The IHS is diverse and rich with experiences

• Mostly rural health care services provided

• Many disparities exist - staffing and age of the facilities

• High incidence and prevalence of chronic disease

• Low per capita funding

Health Care Needs

Health Care Funding

Telehealth as a Business Tool

• To improve service delivery in the face of:– Increasing service population/need– Disparities in:

• Mortality data• Funding• Staffing• Facilities

http://www.ihs.gov/CIO/InfoTech_index.asp

‘Service to the Point of Need’

• For patients, families, and health care teams– Enhancing access

• To care• To health data

– Improving value• For communities• For health system

– Assuring quality• By decreasing variations• Through ‘right time’ health

information

Key Questions

• What are the opportunities for shared/collaborative service delivery?– To help improve ROI

• What is the opportunity specific to chronic care?– To improve access to care, system efficiencies,

and quality of service delivery

IHS Telehealth Program:Leveraging Investments

Integrated HIT System–RPMS-EHR–Vista Imaging–iCARE

Partnerships–Joslin Diabetes Center

Outreach Technology–AFHCAN

Resource Patient Management System Resource Patient Management System (RPMS):(RPMS):

---- A.K.A. ----Really Powerful at Measuring Stuff

Integrated HIT System

– IHS Health Information Solution since 1984

– Comprised of over 60 component applications

– Foundation for the IHS EHR

PCCPatient

Database

Case Management Data EntryReferred Care

Diabetes Management

Elder Care

Patient Registration

Laboratory

Emergency Room

Public Health Nursing

Pharmacy Appointment System Occupational Med

CHR

Radiology

Immunizations

Women’s Health

Dental

Behavioral Health

Clinical Data Integration

IHS EHR

• Graphical User Interface to RPMS– User-friendly access to RPMS database for

clinicians/other staff– ‘Componentized’ architecture

• to allow incorporation of functionality developed within IHS or another agency/organization

IHS VistA Imaging Project

• Implementation of VA’s multimedia program as multimedia software component of the IHS EHR, for: – Scanned documents– Non-DICOM images– DICOM images

iCARE

• Integrated Case Management Application– GUI application– 1st release May, 2007

• Able to:– Create and manage patient

lists or panels– Share created lists or panels– Display outcome

performance measures for any panel

– “Auto-tag” records for pts with specific diagnoses

– Customize layouts– Flag abnormal events/results

for users

iCARE

• Perspectives for:– An individual patient– A clinician’s patients– A population of patients– A community of patients

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Cover Sheet Flags

Re-mind-

ersPt.

GPRAstats

FaceSheet

Health Summary Well-

NessSummary Labs

Meds

Radi-ology

ProblemList

IHS Joslin Vision Network

• Retinal screening for patients with diabetes

• 57 sites nationally in 15 states

• Single reading center at Phoenix Indian Medical Center

• Over 21,000 interpretations completed to date

• Phoenix, AZ• Sells, AZ• Tuba City, AZ• Parker, AZ• Hopi, AZ• San Carlos, AZ• Salt River, AZ• Peach Springs, AZ• Ft Belknap, MT• Crow Agency, MT• Pine Ridge, SD• Rosebud, SD• McLaughlin, SD• Shiprock, NM• Santa Fe, NM• Albuquerque, NM• Mescalero, NM• Crown Point, NM• Fairbanks, AK• Cass Lake, MN

• Livingston, TX• Clinton, OK• Wewoka, OK• Lawton, OK• Eufaula, OK• Okmulgee, OK• Oklahoma City, OK• Pawnee, OK• Ft. Yuma, OK• Winnebago, NE• Lawrence, KS• Warm Springs, OR• Nespelem, WA• Yakama, WA• Wellpinit, WA• Tacoma, WA• Fort Hall, ID• Lapwai, ID• Plummer, ID• Rock Hill, SC

• Elko, NV• Reno Sparks, NV• Schurz, NV• Washoe, NV• McDermitt, NV• Fallon, NV• Ft. Defiance, AZ• Tucson, AZ

– Pascua Yaqui Tribe– San Xavier

• Tahlequah, OK• Jicarilla, NM• Kayenta, AZ• Inscription House, AZ• Montezuma Creek, UT• Blanding, UT• Monument Valley, UT• Navajo Mountain, AZ

Diabetic Retinopathy IHS/JVN Teleophthalmology Program

“Mobile Joslin Vision Network”

• Proof-of-concept to the Artic Circle

IHS-AFHCAN Collaboration

• National Telehealth Infrastructure in Indian Health– Offer a secure enterprise solution for store-and-

forward telemedicine across Indian health

Multi-Modality “Store&Forward” T-Health

AFHCAN Telehealth

• 8 years operational history• R&D Telehealth System• 10,000 cases / year• Manufacturing of Medical Devices• Whole Product Solution

• 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)

Design Installation Training Support Marketing

Product Evaluation

Integrated Systems of Care

• Focus on standards and information systems integration– AFHCAN to be integrated with -

• The IHS Electronic Health Record• And VistA Imaging

New Service Models Possible For:

• Radiology• Retinopathy screening• Mental health• Dermatology• ENT

• Cardiology• Pharmacy• AIDS-HIV care • Neurology• Nutrition/Dietetics

Emerging Capability

• “High Tech”– Broad application

• Tele-pharmacy

– Focused application• Electronic ICU• “Robotic surgery”

– Training

• “Low Tech”– Broad application

• Home telehealth• Medical nutrition Rx

– Focused application• Pediatric specialists

ENT Tele-Consultation Center

• Specialists at Alaska Native Medical Center– Statewide experience via the

AFHCAN network

• Extended in 2006 to patients at the Yakima Indian Health facility in eastern Washington

• Further extension in 2007 to other Indian health facilities outside Alaska– “Expert triage” model

Tele-Pharmacy

• Aberdeen Area– Pilot project began last

summer– Supporting the Pine

Ridge Service unit and surrounding clinics

• Based on work done at ANMC and outside Indian health

Access to “Best Practices” Specialists

• National Jewish Medical Center– Leader in Asthma Care

• University of California, San Francisco– Consultation for patients with HIV/AIDS

Tele-Behavioral Health

• Behavioral health service is an ideal target for telehealth– Growing experience already

within Indian health– Service delivery models ready

to go

• Other ‘real-time’ telehealth is maturing– Cardiology, Rheumatology,

Nutrition services– Reimbursement models

improving

Chronic Care Initiative

PURPOSE:

• Re-engineer clinical programs to more effectively manage chronic disease

• Link community-based primary prevention with patient centered secondary prevention

• Create a healthcare system that is proactive, supportive, and evidence-based

• Promote interactive relationship between informed, motivated patients and prepared/proactive health care teams

Adapted from Wagner EH. Chronic disease management: What will it take to

improve care for chronic illness? Effective Clinical Practice. 1998;1:2-4.

Self-

ManagementSupport

Delivery

SystemDesign

Clinical

InformationSystems

Decision

Support

Community:Resources and Policies

Health System:Health Care Organization

The Care Model

The Care Model

Self-

ManagementSupport

Delivery

SystemDesign

Clinical

InformationSystems

Decision

Support

Community:Resources and Policies

Health System:Health Care Organization

Patient Driven Coordinated

Timely/Efficient Evidenced/Safe

PRODUCTIVE

The Care Model

Self-

ManagementSupport

Delivery

SystemDesign

Clinical

InformationSystems

Decision

Support

Community:Resources and Policies

Health System:Health Care Organization

Patient Driven Coordinated

Timely/Efficient Evidenced/Safe

PRODUCTIVE

1. Develop a multidisciplinary team that optimizes the role of each member in clinic & community

2. Optimize the Care Team: each member performs at the highest level of their licensure.

3. Focus on access, efficiencies and flow

4. Provide clinical case management services for complex patients

5. Give care that patients understand and that fits with cultural background

6. Think about alternative approaches to traditional 1:1 face to face care: telehealth, group visits, etc.

7. Integrate traditional medicine

Self-

ManagementSupport

Delivery

SystemDesign

Clinical

InformationSystems

Decision

Support

Community:Resources and Policies

Health System:Health Care Organization

The Care Model

Informed,ActivatedPatient &

Family

Prepared,ProactivePracticeTeam

Patient Driven Coordinated

Timely/Efficient Evidenced/Safe

PRODUCTIVE

The Care Model

Self-

ManagementSupport

Delivery

SystemDesign

Clinical

InformationSystems

Decision

Support

Community:Resources and Policies

Health System:Health Care Organization

Informed,ActivatedPatient &

Family

Prepared,ProactivePracticeTeam

Patient Driven Coordinated

Timely/Efficient Evidenced/Safe

PRODUCTIVE

IMPROVED ACHIEVEMENTS

Home Telehealth/Remote Monitoring

• Improving literature and experience– Chumbler et al, 2005: 455 VA patients

• 50% reduction in hospitalization• 11% reduction in ED visits• Improved health-related quality of life

– Noel et al, 2004: 104 elderly “high use” VA pts• Decreased hospital bed days, ED visits• Decreased Hgb A1C• Improved cognitive scores• Decreased resource needs, increased treatment compliance

VA Home Telehealth

• 25,000 patients currently enrolled across the VA health system

• For a range of services:– Mental health– Heart Failure, HTN– Diabetes care– Other chronic conditions

Home Telehealth in IHS

• Continues Development– Pros

• Improves patient access to care• Improves chronic care• Extends health care team more efficiently• Decreases inappropriate hospital utilization• Promotes guideline-driven care

– Cons• Reimbursement policy only beginning to take shape

HEARTHealth Enhancement for American Indians & Alaska Natives Through

Residential Telemedicine

‘Success with Failure’

Home Telehealth for Heart Failure

Note: Cost/Hospitalization from Dasta (2005) AHA 6th Scientific Forum on Quality ofCare and Outcomes Research in Cardiovascular Disease & Stroke

POTENTIAL SAVINGS

Economics of Home Telehealth

• Annualized cost per patient ~ $2,500– Includes cost of equipment and shared staff

(new) to oversee day-to-day program

• Annualized savings per patient ~$30,000– Assumes prevention of roughly 1.5

hospitalizations per year for patients with heart failure as primary diagnosis

Home T-Health Reimbursement

• System savings don’t equal individual facility budget savings– Savings to 3rd party insurers vs. individual facility CHS

budget

• Reimbursement policy in home telehealth is still evolving

• And some incentives are “malaligned”– E.g. Decreased hospitalizations are not advantageous to

some referral facility operating budgets

Telehealth Reimbursement

• Medicare reimburses for real-time telehealth

• A growing # of Medicaid programs also reimburse for real-time thealth services

• More Medicaid programs reimburse for some store-and-forward telehealth services– E.g. AZ Medicaid is especially proactive

T-Health Business Models

• Lapsed salaries– Use T-health for unfilled vacancies

• Reimbursement – Relies on 3rd party payer policy and rates

• Cost Avoidance– Eg.For contract health budgets

• Agreements/contracts– Shared costs among facilities/communities for specialist

FTEs/services

Note: Percentages may not add to 100% due to multiple outcomes per case.

About 73% of the patients seen needed something done (meds, surgery, ongoing monitoring) and 27% needed to be screened out.

Alaska ENT Outcomes (n=897)

Next Steps

• Regional telehealth service “menus”

• Continued modeling, with business planning

• Important opportunities for emerging tools to complement/shape new service delivery models– Chronic Care

Collaborations are Key

• Within Indian health– Southwest Telehealth

Consortium– Alaska Federal Health Care

Access Network (AFHCAN)– Inter-Area “corporate”

projects

• With other federal agencies– Veterans Health

Administration

• With universities, states, and other organizations

Thank You