VA Northwest Health Network Veteran Integrated Service Network

(VISN) 20

Joseph L. Ronzio, DHSc, CPHIMS, SMHIMSSVA Northwest Health NetworkVISN Telehealth Coordinator

Tracy Dekelboum, MSWSouthern Oregon Rehabilitation Center and ClinicsFacility Telehealth Coordinator

What is Telehealth?The VHA Office of Telehealth Services states:

Utilizing telehealth 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

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.

VISN 20 CVT ServicesTelemental HealthPacemaker / ICDNutrition and DieticianMoveTraumatic Brain InjuryRehabilitation and AmputeeDiabetesHepatologyPain Clinic

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.

VISN 20 S&F ServicesFor 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.

TeleradiologyEpilepsy EEG diagnostics

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.

VISN 20 HT ServicesDiabetesCongestive Heart Failure (CHF)Cardiac CareHypertensionMental Health Issues: Depression &

PTSDObesity (Tele-MOVE)

VISN 20Description of Challenges of our Network

Largest amount of land of any VA NetworkVery rural locations (Alaska, Southern & Eastern

Oregon)Only two major tertiary care facilitiesHigh non-VA care and beneficiary travel costs

Benefits of our NetworkVA Electronic Health Record – CPRSFrequent communication amongst sitesDecent collaboration and support amongst sitesPre-existing telehealth programs

Telehealth is a natural addition to the healthcare provided

VISN 20’s Telehealth NetworkEstablished a standardized VISN-wide Business

StructureDesignation of Facility Telehealth Coordinators

(FTHCs) to oversee each facility’s telehealth activitiesImplementation 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

VISN 20’s Telehealth NetworkEstablishment of standardized documents

proposing and facilitating all telehealth programs

Business planTelehealth Service Agreement (TSA’s)Standard Operating Procedure (SOP’s)

Establishment of standardized equipment use and purchase amongst all sites of care

Developing a Network WideTelehealth Program

Rural location benefits greatly from telehealth ServicesDescription of demographics/idiosyncrasies of locations

Developing a Telehealth program requires a mix of aggressiveness and hand holdingShare transition of technology to make aware of actual

use of technologyWhat is in it for them?Workload creditIncrease in Patient Access to careAbility to have more meaningful communication with

patientsAbility to be in same room as other provider provides care

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 urbanAll other areas are rural and highly rural

Treatment Sites: One Community Based Outpatient Clinic (CBOC) and one Outreach Clinic

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

SORCC Programs Clinical Video Telehealth

Telemental HealthTele Pain ManagementVeterans Court

Home Telehealth Store & Forward

Teleretinal ImagingTeledermatology

Implement in 2012ArrhythmiaPace MakerHome Based TMH & PCExpansion of Diabetes Health ClinicPre & Post Op Clinic

Involvement in a Network Telehealth Program

Networking opportunity and support amongst FTHCsFrequent communication

Bi-weekly organized callAs 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”

Experience - CVTFY 11 Data

5,747 patient encounters2,296 unique patients1,788,502 patient miles of travel saved

FY10 Data3,358 patient encounters2,391 unique patientsJust over 1M patient miles of travel saved

FY09 Data2,013 patient encounters1,690 unique patients

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 yearsHigher patient satisfaction than clinic based

telehealth servicesSignificantly lower patient now show rates

Less than .5%Traditional mental health care is 12% to 24%Clinic based telemental health is 8% to 18%

Experience – CVTProvider Empowered

Telework is possiblePatients are less stressed upon arrivalPatients with a history of violence

Experience - S&FFY 11 Data

14,596 patient encountersFY10 Data

9,950 patient encountersFY09 Data

8,438 patient encounters

Experience - S&FS&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 complicatedEspecially if you are imaging multiple body

locations with suspected problems

Benefits/Satisfaction/ChallengesBenefits

Increase in Patient Access to careAbility to have more meaningful communication with patientsAbility to be in same room as other provider provides careWorkload credit – telehealth is considered a face-to-face

appointment

SatisfactionHigh Veteran satisfaction both in communication and in elimination

of lengthy travelProvider satisfaction in communication success and ability to be

present during the Veterans’ session with non-SORCC providers, skill building

ChallengesObtaining Clinical Champions to lead effortsObtaining buy-in for participationScheduling provider and room timeCoordination with providing sites

Things to Never ForgetAssure purchase of sufficient bandwidth as there

never seems to be enoughAssure all equipment is compatible and

standardized where possible throughout the network

Develop a systematic approach for Gaining Buy-inBenefit to patient accessBenefit to providersGet to play with cool shiny toys

Importance of Clinical ChampionsTo lead innovationTo support followers

Questions