Telemedicine

Telemedicine & Advanced Technology Research Center Cutting Edge Medical Technology

TATRC

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U.S. AU.S. ARMYRMY M MEDICALEDICAL R RESEARCH ESEARCH & M& MATERIELATERIEL C COMMANDOMMAND

MG Eric B. Schoomaker, Commanding

Deputy for Advanced Technologies

COL Karl Friedl, MC, USADirector, Telemedicine & Advanced Technology Research Center (TATRC)

LTC (Dr) Hon Pak, MC, USA Chief, Advanced Information Technology Group

MEDICAL MATERIEL DEVELOPERProtect the Warrior… Sustain the Force!


TATRC

Disclosure

• Chairman, Standards and Guidelines of ATA• Deputy Chair, Telemedicine Taskforce, American

Academy of Dermatology• President-elect and Board of Directors, American

Telemedicine Association (ATA)• Teledermatology Consultant, Army Surgeon General• Chief, Advanced Information Technology Group,

TATRC


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MISSION

Apply physiological and medical knowledge, advanced diagnostics, simulations, and effector systems integrated with information and telecommunications for the purposes of enhancing operational and medical decision-making, improving medical training, and delivering medical treatment across all barriers.

The program scope is to identify, explore, and demonstrate key technologies and biomedical principles required to overcome technology barriers that are both medically and militarily unique.

Department of Defense,Joint Warfighting Science and Technology Plan, Chapter IX, Joint Readiness and Logistics, 1999


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TATRC Programs

• Congressional Special Interest RDT&E (70+ Programs)

• Office of the Surgeon General AMEDD Advanced Medical Technology Initiative (AAMTI) (70+ Projects)

• SBIR/STTR Small Business Innovative Research/Small Business Technology Transfer (50+ Projects)

• Telemedicine

• DARPA Programs (25+ Projects)


TATRC

“Integrating Telehealth Technologies Into DoD EHR Network”


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Agenda

• Current telemedicine investments

• Arrival of AHLTA- our EHR

• The “gap” of EHR

• Convergence of EHR and telemedicine


TATRC

NAVYMEDCENS

SERMCDDEAMC

GPRMCBAMC

PRMCTAMC

Air ForceMEDCENS

WRMCMAMC 18th MEDCOM

121st General Hospital

NARMCWAMC

WRAMC

Iraq

Kuwait

Afghanistan

Balad (Army & Air Force)

Baghdad

Mosul Arifjan TMC (Army & Navy)

Beuhring

Ali Al Salem (Air Force)

Exams

Work over flow / Medevac

Radiologist

LEGEND

30 July 2002

Theater Teleradiology Business Process

A Theater Approach to SoldierHealth Care: Teleradiology

ERMCLRMC Germany

Bahrain (Navy)

Cropper

Bucca

Talil

Tikrit

Baghram

Kandahar

Salerno

Kabul (Projected)


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Army Telepathology Program

• 13 new virtual slide scanners - $800K

• Infrastructure upgrade for AFIP Telemed - $250K


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Western

Ft. Irwin

Ft. Lewis(MAMC)

Ft. Wainwright

PacificPacificTripler (TAMC)

121st General Hospital

GE PACS

Ft. Monmouth

Ft. Sill

Ft. Drum

West Point

Ft. Carson

Ft. Huachuca

Ft. Hood

Ft. Sam Houston(BAMC)

Ft. Polk

Ft. Knox

WRAMC

Ft. Leonard Wood

Ft. Riley

Ft. Leavenworth Ft. EustisFt. Lee

Ft. Meade

Ft. Belvoir

WBAMC

North AtlanticGreat Plains

Ft. Bragg

Redstone Arsenal

LandstuhlHeidelberg

Wuerzberg

Siemens PACS

Europee

Ft. Jackson

Ft. Campbell

Ft. Stewart

Ft. Gordon (DDEAMC)

Ft. Rucker

Ft. BenningFt. McClellan

Digital Radiology– Where are we today?

Agfa PACSIBM PACS

Southeast

Ft Buchanan, PR

JTF Bravo


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Tele-Health Initiatives Tele-Echocardiology

• Availability of echo depends on access to sonographer, equipment and cardiologist

• Digital echo and telemedicine technology bridge the gap to specialty diagnostic imaging

• All echos are read at BAMC

• Cost savings for MEDDAC– Civilian cardiologist office echo plus

interpretation ~ $600 to $1000

– Our contractor: read cost is $73

• $434.4K funded as Venture Capital (ROI) on FY06 resource summary; transitions to base in FY07 ($452.2K)

Jan 2002 – Jun 2006 – 10,746 exams Purchased care would have cost $3,544,454

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AKO.Consult Program Summary

[email protected] Managed by the Institute for Surgical Research, Ft Sam Houston

[email protected] Managed by BAMC Cardiology

[email protected] 4 Call Teams: BAMC, Walter Reed, Western, and Atlantic

[email protected] On-call ophthalmologists based in Germany and Eastern US

[email protected] (Infectous Diseases) 3 Call Teams: BAMC, Walter Reed, and Western

[email protected] Managed by various Army, Navy, and Air Force call teams

[email protected] (Pediatrics Intensive Care) Walter Reed based with call teams from Hawaii to Germany

[email protected] Preventive Medicine and Occupational Medicine … managed by CHPPM

[email protected] BAMC based with participation by all DoD toxicologists

[email protected] Managed by TAMC with participation from many MTFs


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AKO Teleconsultation Summary• Program Summary

10+ specialties with contact groups: [email protected]

1,886 teleconsultations (April 2004 to July 2006 – 29 months)

47 known evacuations prevented

3 evacuations prevented in August

42 known evacuations facilitated following consultant’s recommendation

5 evacuations facilitated in August

648 different referring health care professionals

250 teleconsultations on non - US patients Average Reply Time 5 hr 9 min


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Tele-Dermatology

• 17,805 consultations since inception of program

• 18 reporting facilities– 188 Army consults or 62% of total

– 92 Air Force consults or 30% of total

– 23 Navy consults or 7% of total

• $825.4K funded as clinical deficiency on FY06 resource summary

Army Site

Air Force Site

Navy Site

GITMO

Feb 02 – May 05 – 12,428 consults answered

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Total Consults Army Consults Air Force Consults Navy Consults


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NARMC Tele-Neurosurgery Optimize Specialty Care

PA screening optimizes neurosurgeon

Conservative care improves clinical outcomes

Recapture related RAD/PT/surgery fees/lab

PA/Nurse Manager provide

case management


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Tele-Behavioral Health (WRAMC) Clinical Business Process

Referral Management and Promotion• MTF managed care staff and Health Net support referrals• Market initiative to beneficiaries at each referring site• Establish referral process/rules to exceed access standards• Review civilian hospital behavioral health admissions daily

Psychiatrist Scheduling• New patients/follow-up/walk-ins/ER patients/MEBs• Therapist screening (triage) to prioritize patients• Immediate aftercare for early release of inpatients

Patient Follow-Up Care• Psychiatrist follow-up VTC visits are based on treatment plan• Psychiatric NP provides VTC med mgmt clinic for stable patients• Therapists take over care for long-term stable patients


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DoD Telemedicine Summary

• Multiple Disparate Systems

• High and Low Bandwidth telemedicine systems

• Live Interactive and Store and Forward System

• Lack of centralized portal for both military and network providers

• Shortage/maldistribution of specialists


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Scope of MHS Operations

Average Weekly Statistics, 2005

• Direct Care Visits: 590,222• Direct Care Admissions: 5,486• Direct Care Dental Visits: 99,000• Direct Care Births: 1,070

• Direct Care and Purchased Care Visits: 1,885,555• Direct Care and Purchased Care Admissions: 20,667• Direct Care and Purchased Care Dental Visits: 104,000• Direct Care and Purchased Care Births: 2,228


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AHLTA Deployment Statistics

• As of 25 Aug 2006:– Full use by 130 out of 138 MTFs

– 56,618 out of 63,000 users trained

– 27.3 million visits captured since Jan 2004

– Contains records for 8.4 million beneficiaries

– Documents 96,800 patient visits per day electronically (per 21-25 Aug 2006 survey)

– Contains 544,000 theater patient encounters

– 32,000 encounters sent from Theater to Garrison in July 2006


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Telemedicine Gap of AHLTA

• The “gap” of EHR– Autoregistration of virtual patients– Workflow: Ability to route consults outside

network or facility– Ability to order consults with images– Workload capture/split

• Professional v. Acquisition


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Integration effort

• Telehealth Portal

• Others– Tricare On Line– DFI– Document Engine (workflow)– EWRAM


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TRICARE ON-LINE (TOL)

• Portal for MHS Clinicians and Beneficiaries• Single Sign On (SSO) to MHS Applications under

development• Linked to DEERs for eligibility checking• Primary Means To Support Consumer Empowerment

– Can make appointments– Pharmacy refill under development– Health Content for Patient Reference– Health Assessments– Deployment related links– Non-availability statements– Personal Health Manager (journal and tracker) and Personal Health

Record (demographics, allergies, medication and appointment profiles) under development

– Home Page being re-designed


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TRICARE Online (TOL)Schema

BeneficiariesProviders/

Staff

External Support Contractors

Single Sign-OnMilitary Health System

(MHS) Portal SSO

Defense Medical Human Resources System – internet

(DMHRSi)

Patient Safety Reporting (PSR)

CHCS

Defense Enrollment and Eligibility Reporting System (DEERS)

Current TOL Applications and Services

Single Sign on to MHS Systems(in progress)

104 Military Treatment Facilities

Health Content

DeploymentRelated Links

Secure Provider Access CHCS (SPAC)

Portal to PortalSingle Sign-OnServices to TOL

Others

Health Assessment

Centralized Credentials & Quality Assurance System

(CCQAS)

Deployment Related Medical Records Online (DRMROL)

AHLTA/Clinical Data Repository

Non Availability Statements (NAS)

Composite Health Care System - CHCS

Service Portals

Appointing

ExternalSystems


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TRICARE OnlineCurrent Capabilities

• Online appointing– Automatically checks eligibility for care

• Information on MHS Services and Benefits

• 18 million pages of Health Content

• Online drug interaction checking

• Non-Availability Statement (NAS) processing

• Secure Access to Composite Health Care System (CHCS)

• Access to Deployment Related Records Online (DRMROL)


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Document,Files,Imaging (DFI)

• Provides ability to capture, identify, and present DFI to the clinical user within the context of clinical workflow.

• Current MHS environment presents numerous instances in which in hard copy and digital clinical encounter documentation originating from outside sources needs to be incorporated into AHLTA

• This project is essential for ensuring that the healthcare professional has a complete and comprehensive record for use while delivering quality patient care.


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AHLTA Client

DFI module

• DFI List• DFI View

Scan/Import Tool

DFI Management Sub-System

DFI Repository

• DFI Retrieval Service•DFI Import Service

View Purchased Care Data

ElectronicDocument

[Future]MTF PACS (Agfa Web)

Broker for person Identifier

(DEERS PIDS fetch)Indicates Scanning/Import Tool ECP 915Indicates Digital Imaging ECP 920Indicates View Purchased Care Data ECP 919

DFI Registry

• DFI Registry Query Service

• DFI Registration Service

• Scan/Import

Paper Document

Document, Files, Imaging (DFI), continued


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Document Engine/AHLTA Integration System Architecture

DE

Legends:AvailableTo BeImplemented

Oracle HTTP Server

Document Engine Server

OC4J (J2EE) ContainerDE Application

DE WebServices

TranscriptionSystem

LCS S

erv

er

JDBC

Tra

nscri

bed d

ocs

HL7

Messag

es:

A

DT,

SC

H …

HL7

Messag

es:

A

DT,

SC

H …

HL7

DocumentCapture Driver

AHLTA Client WS

DocumentCaptureApplet

IntegrationB2B

HL7Engine

Syst

em

Pri

nt

Serv

ices

Port 443Port 443

Listener Port (e.g. 1521)

LGSFEP #2 Server

GenericInterface

Port

443

Pulmonary FunctionSystem

Medical Records Printers

CHCS

AHLTA DE Web Services

AHLTADE

Module

ICD

CoreModule

DE

XML Proxy CDR

Listener Port (e.g. 1521)

CWSFEP

ICD Enc.Mapper

CDR Enc.Mapper

EncounterMapper


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Document Engine (DE)

• DE module provides a universal, standard interface for incorporating clinical documents into patient records. Comprehensive information capture is provided from the following:

– Clinical text Health Level Seven (HL7) messages,

– Print jobs from other Windows applications, and

– Print jobs via serial port data from legacy hardware devices.

• Project to integrate GOTS Document Engine (DE) into AHLTA to provide interface to import documents from external vendors, other print-capable Windows software, and legacy hardware.

• Allows users to manage unsigned documents through a delegation, review, and signing workflow.


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Enterprise Wide Referral and Authorization Module (EWRAM)

• Background:– Per HIPAA Law, covered Entities are Required to use

Standard Transactions (X12 278) for all Electronic Referral & Authorization Requests

– If MHS Sends / Receives Electronic Referral Request, (X12 278) Required

– Faxing Not Considered Electronic

– Long History of Development of CONOPS through Flag-led WIPT and negotiations with MCSCs on what is required


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Enterprise Wide Referral and Authorization Module (EWRAM)

• HIPAA R&A WIPT: HIPAA OIPT Referral & Authorization (R&A) WIPT Created to Address Direct Care Business Process & HIPAA R&A Transactions Between MTF and MCSC

• EWRAS: Enterprise Wide Referral and Authorization System

• NAS: Non Availability Statements: Permits TRICARE Non-enrolled Beneficiaries to Receive Inpatient Care in the Civilian Market (NDAA 2002 – Mental Health Care only); Europe Uses NAS System For Referrals

• EWRM: Enterprise Wide Referral Management IPT

• EWRAP: Enterprise Wide Referral and Authorization Process IPT

• M-EWRAS: Modified-EWRAS as a CHCS II Module

• EWRAM: Enterprise Wide Referral and Authorization Module


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EWRAS Interfaces

MCSCTOL

CENTRALSERVER(at DISA)

REFERRINGPROVIDER ENTERS

REFERRAL INTOEWRAS

MTF HUB

DEERS

CHCS

Ref.

Approved to

Direct C

are A

ppointmen

t

271

270

HL

7

278Civ Net

INT

ER

FA

CE

E

NG

INE

Referral Request,Status Updates,& Results

271270

INT

ER

FA

CE

E

NG

INE

MCP Request, Appointment

Specialty Provider or Transcriptionist Enters & Verifies

result intoEWRAS

• High Reliability & Availability

• Local Redundancy


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Telehealth Convergence

• Telehealth as portal into AHLTA• Single Point of Entry

– Network providers– MHS providers

• Deployed Environment• Fixed Facilities• From Specialist’s Home or remote location

• Seamless workflow with AHLTA– Single view/ desktop– Leveraging existing and ongoing functionalities– Process over existing infrastructure


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Telehealth Portal

• Outsourcing Specialists– Most of our patients are seen by our network providers

(Tricare)– Leveraging telehealth to optimize delivery of healthcare– Contract Process (Tricare Contract)

• Ensure that Telehealth is used especially when specialty access is not available by traditional means

• Second Opinion– CDC– Subspecialty Care

• Pediatric genetics


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Summary

• Telehealth Portal from Walter Reed– Require backend integration with Tricare On Line

• Gap Analysis and Convergence– Tricare On Line– Document, File, Images– Document Engine– EWRAM


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Questions

• Hon Pak

• [email protected]

• 301-619-7923

Date post:	15-Dec-2014
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Telemedicine

Health & Medicine