AMEDD Telehealth Overview Briefing to the ATA/TATRC

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AMEDD Telehealth OverviewBriefing to the
ATA/TATRCAdvanced Briefing for Industry

• COL Ron Poropatich
• TATRC Senior Clinical Advisor
• 2 December 2004

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Telehealth References

• "Innovation, Demand and Investment in
  Telehealth", Dept. of Commerce Report from
  February 2004 http//www.technology.gov/reports/Te
  chPolicy/Telehealth/2004Report.pdf
• Revolutionizing Health Care Through Information
  Technology, Presidents Information Technology
  Advisory Committee, June 2004
• http//www.nitrd.gov
• The "Framework for Strategic Action" for "The
  Decade of Health Information Technology
  Delivering Consumer-centric and Information-Rich
  Health Care by Dr. Brailler (HIT czar) and Secy.
  Thompson, July 21, 2004.
• http//www.hhs.gov/onchit/framework/hitframework.
  pdf
• The Doctor is Online Secure Messaging boosts
  the Use of Web Consultations, Wall Street
  Journal, September 2, 2004

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Telehealth VisionEnabling Technology
Graduate Medical Education
Health Care Delivery
Telehealth
Operationally relevant
Research Development

• Desirable Characteristics
• Applied regionally
• Defined outcome metrics
• Self-sustaining
• Technically feasible
• TNEX considerations included

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U. S. Army Medical Department Telemedicine
Organization

• Telemedicine Advanced Technology Research
  Center (TATRC), Fort Detrick, MD
• Manage Advanced Medical Technology competitive
  research programs - congressionally directed
  OTSG sponsored
• Support Operational Telemedicine deployments
• Telehealth Program Office (TPO), Fort Detrick,
  MD
• Army PACS Program Management Office (APMMO),
  Fort Detrick, MD
• Regional Medical Commands
• Tripler Army Medical Center, Honolulu, HI
• Madigan Army Medical Center, Fort Lewis, WA
• Brooke Army Medical Center, San antonio, TX
• Walter Reed Army Medical Center, Washington, DC
• Dwight David Eisenhower Army Medical Center,
  Augusta, GA
• Landstuhl Regional Medical Center, Germany

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U. S. Army Telemedicine Program

• Secure Web based programs (Store Forward)
• Dermatology
• Ocular health
• Cardiology (adult child))
• Pediatrics
• Pathology
• Radiology
• Interactive real-time consultations
  (Video-conferencing)
• Maternal Fetal Medicine
• Genetic Counseling
• Nutrition Care
• Tumor Board
• Psychiatry (adult child)
• Neurology (Headache clinics)
• Neurosurgery
• Distance Learning
• Weekly CME eRounds
• Combat Medic (91W) skills training
• Medical Awareness (CDC Broadcasts etc.)

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AMEDD Corporate Investment in Telehealth

• World-wide deployed capability
• Radiology (63 DICOM servers)
• Pathology (22 systems)
• Ophthalmology (LRMC, WRAMC, TAMC)
• Dermatology
• MEDCEN expertise
• BAMC
• Dermatology 500 consults /month
• Cardiology 200 Echos/month
• TAMC
• Pediatrics 30 consults/month
• WRAMC
• Psychiatry 130 consults/month
• Neurosurgery 25 consults/month

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TeleHealth Prioritiesfor the TOE/TDA

• Order of Merit
• Tele-Radiology
• Tele-Dermatology
• Tele-Pathology
• Tele-Ocular
• Tele-Psychiatry (Adult)
• Tele-Echocardiography
• Tele-Neurosurgery
• Tele-Pediatrics

• Evaluation Criteria
• Functional Proponent
• Consultant Engaged
• Level of Financial Investment to date
• Demonstrated Clinical Business
• Process Model
• Business case Analyses
• Medical Commanders Support

Top Priorities
( indicators but not well positioned at this
time)
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Telehealth IM/IT Strategy
CIO/ACSIM BCA Facilitation MEDCOM 25-1
OTSG

• 100 M
• 10 years

• Mature Technologies
• Tele-Derm
• Tele-Mental Health
• Tele-Neurosurgery
• Tele-Pathology
• Tele-Echo
• Tele-Radiology
• Tele-Ocular

• Subject Matter Experts
• Col Poropatich
• Clinical Consultants
• TPO Team

AMEDD Implementation Based on BCA
MRMC Materiel Developer - Logistician
AMEDD CS DOTMLPF Facilitation Capabilities
Development Training
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FY 04 Year in Review

• Telehealth IPT Chartered- October 2003
• Telehealth Program Office at MRMC Established -
  Nov 2003 (450K UFR to MEDCOM)
• AMEDD/TMA Telehealth Summit-Dec 2003
• Teleconsultation Requirements submitted as part
  of the FY06 POM Process ( 225 e-Health
  Capability)
• AKO Teleconsultation Service for the Deployed
  Forces - initiated April 2004
• AKO Teledermatology Policy signed May 2004
• AMEDD Telehealth Policy signed - June 2004
• Telehealth Deployment to OIF theater June 2004

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Telehealth
E-Health /Telemedicine is the delivery of
consultation and diagnosis using
telecommunications and informatics as a remedy
for difficult to serve, underserved, or expensive
to serve patient populations.
MHS Domain

• Access to Care

• Focus on Our Customers/ Sound Clinical Business
  Practices
• Protect and Sustain a Healthy and Medically
  Protected Force

BSC Goal
BSC Objective(s)

• Return Soldiers to Duty (IP-6)
• Healthy Soldiers (C-1)
• Streamline Access to Care (IP-10)
• Eliminate the Hassle Factor (C-10)

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Organizational Fit
VA
Organizational Fit
MEDDAC
BAS
TMC
Foxhole
MEDCEN
CHCS II

CHCS II-T
MHS Pop Health Solution
IPT
IPT
HealtheForces, MAMC ICDB, TAMC CPG, esiCHCS,
ICDB, MEDBASE,
IPT
IPT
Immunization Medbase, e-Immune, MEDPROS, DEERS
Telehealth
BMIST, MC4, CHCS II-T, MEDBASE, MEDPROS, PIC
Health Surveillance
Longitudinal EMR
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Interim Build Migration Strategy
Ocular
Mental Health
Orthopedics
Full Operating Capability
Cardiology
Dermatology Radiology
Teleconsultation
Current 04
MTF
Application Layers
A fully telehealth enabled organization-integrated
with CHCS II, TOL, EWRAS, MEDIA, EWS etc.
AMEDD Telehealth Portal (Interim)
Integrating Experience
Internet
Medical Education
Leverage existing Teleradiology Infrastructure
to accelerate interim solution
Leverage Interim Operating Capabilities
Future
CHCS II etc.
CHCS I
Longitudinal EMR developed and fielded
FY05
FY07
FY08
FY10
FY011
FY06
FY09
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Operational Telemedicine
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OIF2 Medical Situation

• Problem Ad-hoc teleconsultation process using
  non-secure email systems and an undefined
  business process between deployed providers and
  medical specialists at Level 5.
• Outcome No medical control
• Major Goals
• Secure medical communications
• Streamline medical communications
• Support readiness
• Further define the Requirement for
  Teleconsultation between Levels 2-4 and Level 5.

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Operational Telehealth Applications

• High Bandwidth working with Signal Corps
• Radiology
• VTC Psychiatry Surgical mentoring
  (Neurosurgery)
• Low Bandwidth - AKO (email with JPEG images)
• Dermatology (derm.consult_at_us.army.mil)
• Ocular (eye.consult_at_us.army.mil)
• Burn care management (burn.consult_at_us.army.mil)
• Cardiology (ECG Echocardiograms)
• Dental
• Pathology NIPRNET based
• Medical Maintenance equipment repair

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AKO Telehealth e-mail groups

• Established
• Dermatology Ocular
• Planned
• Burn, Trauma, Infectious Disease
• Cardiology, Nephrology, GI
• Medical Ethics
• Requires administrative support to manage and
  collect data (seeking GWOT funds)

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E-Mail Consultation
Theater Provider
AKO MAIL
MEDCOM E-MAIL
P
P
P
P
P
TMED STATS
P
P
P
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OIF2 Telehealth Reach-Back Architectures
times X
Provider and Patient
Notify
Manage
Monitor
Track
Archive
Audit
OPERATIONAL ARCHITECTURE
Broker
Consultant
Levels II-IV
Level V
SYSTEM ARCHITECTURE
ICDB
CHCSII
CHCS
E-mail
times X
E-mail
INTERNET
Not integrated with other health systems
Need 2 Consult Brokers (GWOT request - 240K)
Many other competing systems
For instructional purposes only
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AKO TDERM SUMMARY

• 390 consults 1 April 2 Nov 04 (7 months)
• 22 Participating dermatologists (from all RMCs)
  since 1 April
• 117 Different Referring Providers
• 8 Providers have submitted 31 of all consults
• 78 providers have submitted 1-2 consults
• Origination Iraq, Kuwait, Bosnia, Afghanistan,
  USS John F. Kennedy (aircraft carrier) Egypt,
  Qatar, Pakistan, MFO Sinai, Germany (SMART Teams)
• 13 of all consults have originated from Camp
  Arifjan, Kuwait
• Many sites cannot disclose location over
  un-secure email

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AKO TDERM SUMMARY

• Demographics
• Male 79 /Female 21
• Median Age 30 years old
• Top Diagnoses - 10 Categories provide 55 of all
  consults
• Dermatitis(most common)
• Eczema
• Tinea
• Nevus
• Utilization by Service
• Army 77
• Air Force 4
• Marines 3
• Navy 5
• Non-combatants (children, civilians etc. referred
  by PCMS with Civil Affairs) 3
• Contractors 2
• Detainee/EPW 1
• Not stated or applicable 5

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AKO TDERM SUMMARYMetrics

• Performance
• Average response time 4 hrs 31 minutes (to date)
• Customer feedback 100 positive
• Consults well-thought out, relevant to end-user
  and complete
• Reasons for Consultation
• Most use AKO for 2nd Opinion
• Training and support by Dermatologists giving
  options to providers in constrained situations.

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Mission Benefits

• Estimate 17 evacuations prevented
• Return to Duty to support the mission
• Avoids costly 3 week process to evac and
  return-avoids lost man days
• Inter-theater coordination
• Consult manager facilitates care between units in
  Iraq and MAJ Smith who runs a Combat Dermatology
  Center part-time (he is the only Derm in theater)
• Expedited definitive care
• Coordinated care through the system from theater
  to MEDCENS
• Facilitation of appropriate care 2 evacs (one
  military and one contractor) recommended due to
  the severity of the problem.
• Quality of Care
• Ensure standards of care in a theater without a
  Dermatology service.

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Telederm Costs Savings

• Assumption- 600 consults annually if utilization
  remains stable.
• (Current rate 50 consults/ month x 12 months
  600/year)
• Cost Estimates
• Dermatologists (avg. 20 mins/consult _at_ 100/
  hour) 33
• Consult Management Admin (30 mins per consult
  at 40/hour) 25
• Corporate Oversight/Overhead 1 hr/week
  90/hour 4,680/year 9
• Platform/ Bandwidth (no additional cost)
  0
• Equipment (no cameras purchased as part of this
  effort) 0
• Training ( no formal training-instructions
  circulated on-line) 0
• 
  
  TOTAL.. 67
• (Annualized at current rate of utilization is
  40K per year)
• Cost savings
• - 17 Medevacs avoided at a savings of 340K.
  Data collected via a survey at time of consult
  reply. based on a cost of 20K per evacuation
• - Lost duty time 3 weeks average for LRMC
  evaluation (357 lost duty days)

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AKO Tele-Ocular

• 11 consults in 3 months (2 from optometrists, 9
  primary care)
• Response Time 6 hrs 18 min
• Demographics
• Average Age 23
• Active Duty 8
• Non-combatant 1
• Reason for Consult
• Routine care (dry eyes) to Post Trauma evals
• 1 Consult to inquire about Preventative eye wear
• Requests for Information only
• Origination
• Iraqi, Afghanistan, Kuwait and Kosovo

Ophthalmomyiasis Tallil Air Base, Iraq 4 Nov 04
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Iraq
USAF MTF Balad
67th CSH
31st CSH
Telehealth Capabilities Dermatology Dental Radiolo
gy Pathology Ocular
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Kuwait
Telehealth Capabilities Dermatology
Camp Buehring (Udairi) USA Level II
Camp Doha USA Level II
Ali Al Salem USAF Level II
Camp Arifjan USA Level IIUSN Level III
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Kuwait Theater Telehealth Needs

• Problem
• Lost duty time to travel to medical specialty
  clinics (Rad/Ortho) 4 hour TAT
• Patient needs escort, driver attendant
• Radiology 600 patients/month require imaging
  from remote sites
• Orthopedic Surgery 20 patients/month
• Translates into 22,320 personnel on Kuwait
  highways/year
• Consultative vs. Diagnostic quality of image
  intepretation
• Cost savings/ ROI
• 22,320 personnel x 4 hours 89,280 hours of
  lost duty time
• Safety concerns - auto accident exposure

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Afghanistan

• TF 325 Med
• (Bagram)
• Telehealth capabilities
• Radiology
• Dermatology
• Neurosurgery

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Required Steps for Telehealth Sustainment in FY05

• Continued Executive Leadership support
• Telehealth Vision-Strategic Plan
• Governance
• Stable and Reliable Funding Source
• MRMC/CS/OTSG Collaboration
• Software Development/CHCS II integration
• Functional Support w/ Defined Clinical Business
  Process
• Business Case Analyses
• DOTMLPF prior to Fielding

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Conclusions

• Telehealth is a valid requirement for the AMEDD
• Telehealth practice is actively providing mission
  and costs benefits.
• Telehealth is now a set of individualized
  capabilities but should be one entity
• Telehealth should be systemized and scaled
• Dedicated Bandwidth is the rate limiting resource
  for operational telehealth requires GO Signal
  Corps support