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Alaska Native Tribal Health Consortium 1
The AFHCAN Telehealth ProgramStewart Ferguson, PhD
Chief Information Officer (CIO)Alaska Native Tribal Health Consortium
Context The Role of Telemedicine Impact of Telemedicine Financial Model for Telemedicine The Future
Alaska Native Tribal Health Consortium 2
ALASKA
• 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.
National Travel and Safety Board (NTSB) reported 436 commuter aircraft accidents in Alaska from1990-2004 (2.8 accidents a month) - accounting for 36% of all commuter aircraft accidents in the US.
• 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.
Alaska Native Tribal Health Consortium 3
ALASKA’s 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– 579 Community Health Aides in 200 villages provide nearly ½ million
encounters each year.AI/AN U.S. Gap
MD 73.9 220.6 66% Lower
DD 24.0 61.8 61% Lower
Nurse 229.0 849.9 73% Lower
DISPARITIES:Health Staff per 100,000 people
Alaska Native Tribal Health Consortium 4
Point Hope
Kotzebue
Anchorage
Rural residents travel an average of 147 miles one wayfor access to next level of care.
Ann ArborChicago
Washington DC
Alaska Native Tribal Health Consortium 5
CONTEXT
ALASKA NATIVES ARE THE HEALTHIEST PEOPLE IN THE WORLDANTHC VISION
Alaska Native Tribal Health Consortium
Years of Potential Life Lost, Alaska Natives, 2004-08
0 5000 10000 15000 20000
Diabetes (n=39)
COPD (n=96)
Pneumonia/Influenza (n=35)
Cerebrovascular Disease (n=70)
Homicide (n=56)
Chronic Liver Disease (n=114)
Heart Disease (n=328)
Cancer (n=555)
Suicide (n=250)
Unintentional Injury (n=451)
n=number of deaths before age 75 years
Source: Alaska Epidemiology Center, ANTHC; Alaska Bureau of Vital Statistic
Alaska Native Tribal Health Consortium
Alaska Native Tribal Health Consortium 8
Historically, Alaska Native and Canadian First Nations populations have been burdened with a high prevalence of otitis media and associated morbidity.
The incidence of ambulatory care visits related to otitis media for American Indian and Alaska Native children is twice that for all U.S. infants.
The placement rate for tympanostomy tubes in these children less than age five was 20 times higher in Alaska compared to the continental U.S.
Alaska Native Tribal Health Consortium 9
Alaska Tribal Health System
• 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.
Alaska Native Tribal Health Consortium
• 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
Designing A Primary Care Tool
10
Alaska Native Tribal Health Consortium
A User Interface Designed by Users
11
Alaska Native Tribal Health Consortium 12
AFHCAN Telehealth Program Managed by ANTHC Federally funded 28 Staff 11 year Operational History
33,000 cases/year131,628 Cases (ATHS)
Installed Customer base includes: Alaska: 248 sites, 44 organizations
59 operational systems in 20111,443 providers in 201122,763 patients in 2011 (16% of AN pop)
Other states and countries
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Case
s Cre
ated
Cases Created per Year
Alaska Native Tribal Health Consortium 13
THE ROLE OF TELEMEDICINE
Alaska Native Tribal Health Consortium 14
We only assume patients travel to nearest region
Alaska Native Tribal Health Consortium 15
Role of Telemedicine
• S&F– 3% of encounters– Primary Care (75%)– Specialty Care (25%)– Triage / Planning– Discharge Planning– Esoteric : Abuse …
– Teleradiology– Telepharmacy
• VtC– Cardiology– Liver/Hepatitis– Pediatrics– Breast Cancer
Screening– Mental Health / API
• RPM
AudiologyCardiologyCare Coordination CenterDentalDermatologyEmergency DepartmentEndocrinologyFamily MedicineGastroenterologyHISInternal MedicineNeurosurgeryOpthalmologyOrthopedicsOtolaryngologyPediatrics-OutpatientPodiatryPulmonologyRheumatologySurgeryUrologyWomen’s Health
Alaska Native Tribal Health Consortium
By the numbers …
16ATHS (Alaska Tribal Health System) (1/1/2001 to 3/31/2012)
131,62865,314
2,9681,854
Cases created
Patients served
Providers involved
Providers creating
Alaska Native Tribal Health Consortium 17
IMPACT OF TELEMEDICINE
Alaska Native Tribal Health Consortium 18
Best for patient care
Helps me communicate with a doctor
Saves my organization money
Most convenient to the patient
Improves patient satisfaction
Makes me more efficient
Gives me confidence in doing the right thing for the patient
Increase access to care
0% 10% 20% 30% 40% 50% 60% 70%
Why do you do Telemedicine?
• Best for patient care• Increased access for care
Alaska Native Tribal Health Consortium 19
Telehealth Impact on Extended Waiting Times (> 4 months)
Data courtesy of Phil Hofstetter
47%
8%
3%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Pre-Telemed1991-2001(n=1216)
With Telemed
2002-2004(n=276)
With Telemed
2005-2007(n=210)
Perc
ent A
ppoi
ntm
ent A
vaila
bilit
y W
ith
5 M
onth
or L
onge
r Wai
t Tim
e
Alaska Native Tribal Health Consortium 20
Deployment of the IHS-JVN in Alaska using a portable platform reversed a seven year decline in rates for the state
Joslin Vision Network (JVN)Portable JVN Pilot
20002001
20022003
20042005
20062007
20082009
0%
10%
20%
30%
40%
50%
60%
70%
DR
Exam
Rat
e
15% Increase
25% Decrease Portable JVN implemented
Alaska Native Tribal Health Consortium
Pre-Operative Planning for Ear Surgery Using Store-and-Forward TelemedicineJohn Kokesh M.D., A. Stewart Ferguson Ph.D., Chris Patricoski M.D.
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)
0%
5%
10%
15%
20%
25%
30%
35%
40%
-3 -2.5 -2 -1.5 -1 -0.5 0.5 1 1.5 2 2.5 3
Perc
ent o
f Pati
ents
Actual Surgical Time - Planned Surgical Time (hrs)
NonTelemed
Telemed
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
Alaska Native Tribal Health Consortium 22
$0
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
$6,000,000
$7,000,000
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Annual Travel Savings (by Case Role)
Primary Care Specialty Care
Alaska Native Tribal Health Consortium 23
Speed of Reply
91%
73%
59%
43%
28%
0%
20%
40%
60%
80%
100%
% C
ases
Turnaround Time
1 Day Same Day 4 Hour 2 Hour 1 Hour
Alaska Native Tribal Health Consortium
How important is the speed of reply?(% “Extremely Important)
• Speed of response is clearly more important to Initiators compared to Consultant
• High User Initiators - 43% rated this 5 out of 5 (“Extremely Important”)
24
High Use
r (Initiator)
High Use
r (Consu
ltant)
Medium U
ser (
Initiator)
Medium U
ser (
Consulta
nt)
Low U
ser (
Initiator)
Low U
ser (
Consulta
nt)0%5%
10%15%20%25%30%35%40%45%50%
When using AFHCAN for patient care – how important is the speed of reply of the consulting doctor?
Alaska Native Tribal Health Consortium 25
THE FINANCIAL MODEL FOR TELEHEALTH
Alaska Native Tribal Health Consortium 26
Medicaid-Eligible Patients
A total of 5,925 telehealth specialty consults with provided to 3,663 unique patients.
$0
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
$70,000
2003 2004 2005 2006 2007 2008 2009
Medicaid PaymentsMedicaid payments totaled $269,893 to ANMC for specialty telehealth consults.
Alaska Native Tribal Health Consortium 27
We only assume patients travel to nearest region
Alaska Native Tribal Health Consortium 28
Medicaid Study: 2003-2009Decreased Travel = Cost Savings
Quantity Cost
Claims Paid by Medicaid 4,482 ($269,894)
Telemedicine Prevented TravelNotes:• Travel is saved for 75% of all patients. • Assume all patients under 18 need an escort• Travel costs based on 1 week advance fares
3,662 $3,116,034
Net Savings Realized by Medicaid $2,846,140
Note: For every $1 spent by Medicaid on reimbursement, $10.54 is saved on travel costs.
Outreach clinics saved another $3.4m in travel costs
Alaska Native Tribal Health Consortium 29
In FY11, 301 pediatric patients were transported from the YKHC by LifeMed at a cost to Medicaid of $2.86 million
Average cost: $9494 per patient
Telehealth may prevent 20% of such transports
Alaska Native Tribal Health Consortium 30
In FY11, the total amount spent on non-emergent medical travel and accommodation for all IHS patients in Alaska was $38.6 million
Patients aged 0-18 years accounted for 53.7% of all travel & accommodation costs statewide
Alaska Native Tribal Health Consortium 31
THE FUTURE
Alaska Native Tribal Health Consortium
The New Limiting Step
Alaska Native Tribal Health Consortium
Growing Usage
33
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1 2 3 4 5 6 7 8 9 10
High & Medium Users (11 YR) n=14
High & Medium Users (10 YR) n=10
High & Medium Users (9 YR) n=6
High & Medium Users (8 YR) n=5
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1 2 3 4 5 6 7 8 9 10
High & Medium Users (10 YR) n=8
High & Medium Users (9 YR) n=13
High & Medium Users (8 YR) n=5
High & Medium Users (7 YR) n=4
Alaska Native Tribal Health Consortium
0500
1,0001,5002,0002,5003,0003,5004,000
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012(Proj)
Case
s Cre
ated
Cases Created per Year• Good will and
commitment• Earned time off for
volume done• Provider time allocated
to telemedicine• Financial incentive to
do the “additional” work
Improve Performance with Scale
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
2010 Q4 2011 Q1 2011 Q2 2011 Q3 2011 Q4 2012 Q1
Med
ian
Turn
arou
nd T
ime
(Hrs
)
Median Turnaround Time (hrs)
Alaska Native Tribal Health Consortium 35
The Commoditization of Telehealth
• Telehealth will part of a blended health visualization– Video, Audio, Health Record, Images, Devices
• Lightweight commodity platforms– Portable, direct to desktop– Integrated into local EHR– HTM will evolve to smart systems, full integrated
• Leverage large scale infrastructures e.g. MPI
Technology is a STRATEGY to
improve performanceand to manage
costs & risk
Alaska Native Tribal Health Consortium 37
Pay for Value
• Simplified Fee Structures– Existing coding poor match
• Business models will move well past “fee for service” concepts - eVisits, employee plans, systemic approaches.
• Fee for Service will not be as relevant. Bundled case management plans and other plans make more sense.
Alaska Native Tribal Health Consortium 38
Drivers for Different Business Models
• Telehealth is only a financially viable solution at scale• Scale is HARD.
– Few models for maximizing performance at scale– May drive Buy versus Build outsourced care
• Need risk avoidance models e.g. ACO, HMO• Demand will continue to outstrip resources
– Non traditional usage models for efficiency gains– Innovative pilot models needed – opportunity exists
• Market differentiator – Empower consumers• Need business models NOT based on reimbursement