Commissioned Officers Association

1
Making It Work
Engineers Enhance Healthcare Delivery though
Telemedicine and Teleradiology

• Commissioned Officers Association
• Annual Meeting-2001
• Mark R. Thomas, P.E.
• Prinicpal Clinical Engineer
• Alaska Area Native Health Service

2
The Indian Health Service

• Who we are
• The challenge facing us
• The telemedicine/teleradiology solution

3
A health care system for the first Americans
4
49 Hospitals in 14 Locations
Mescalero, NM
Acomita-Canoncito-Laguna, NM
Alaska Native Medical Center Anchorage Alaska
Owyhee Tribal Hospital, Nevada
Hu Hu Kam, Sacaton Az.
5
IHS mission, goal, and foundation
-raise the health status of Indian people -ensure
medical community services to Indian
people -uphold treaty obligations to Indian
people
6
Most IHS locations are
7
The Alaska Challenge Geography

• Insert Picture of US dispersion of programs

8
Alaska-Partnering to take on the Challenge

• IHS - 194 sites - 97,000 beneficiaries
• VA - 1 site - 65,000 beneficiaries
• DOD - 9 sites - 47,000 military and dependents
• USCG - 4 sites - 3,000 beneficiaries
• Alaska DPHN - 26 sites

9
The Challenge Geography

• Insert Picture of US dispersion of programs

10
Village Health Clinics

• 168 Remote Locations
• Staff 450 CHA/Ps
• 300,000 OPE/Yr
• 3M Equipment

11
Patient Transportation

• 90,000 Med-Evacs/Yr
• gt 40 M / Yr

12
New Technologies-Handheld Examination Deivces
13
New Technologies-Imaging Devices
14
New Technologies
15
(No Transcript)
16
Telemedicine Workstation Assembly Line
17
Alaska Native Health System
I need text
I need to

• Alaska Native Medical Center
• 7 Regional Hospitals
• 5 Physician-Based
• Health Centers
• 22 Physician
• Assistant
• Health Centers
• 168 Rural Village
• Health Stations

18
Alaska Native Medical Center

• 150 Bed
• 5,000
• Disch/Yr
• 225,000
• OPE/Yr
• 50,000
• Radiology Studies/Yr

19
Existing Telecom Infrastructure

• Satellite Only (Low-Bandwidth)
• POTS Modem 9600 bps
• Frame Relay 56Kbps

20
PHASE I - TELEMED BASELINE RESEARCH

• Phase I - Needs Assessment
• Phase I II - Evaluation Methodology put in
  place (Phase I) performed (Phase II) by
  University of Alaska - Anchorage (UAA)
• Funded through National Library of Medicine
• Contract N01-LM-6-3540
• 3 Million, Over 3 Years
• 25 Villages

21
PART B - TELERAD PILOT PROJECT

• Phase I - Teleradiology Pilot Project
  (Dillingham) with Connection to ANMC PACS
  (Anchorage) Image Compression, Transfer,
  Storage, and Display
• Funded through Indian Health Service
• 450,000 Lease/Purchase
• Shared Maintenance Plan
• Compatible with other
• Alaska Federal Healthcare Partnership sites

22
PHASE II -

• Needs Assessment yields need for treatment of
  Ear Pathology

23
PHASE II - TELEMEDICINE COUNTRY

• Phase II - NLM Contract
• Demonstration Project Locations
• Anchorage Hub
• Demonstrations in 5 villages and 1 regional hub
  in 5 geographical regions
• Bristol Bay South Central
• Kotzebue Yukon-Kuskokwim
• Norton Sound

24
PHASE II - LOW-BANDWIDTH TELEMED SITE
COMPONENTS

• Equipment Cart
• Computer w/
• Frame Grab SW,
• Store--Forward
• E-Mail type SW
• Video Otoscope,
• Video Monitor,
• Other Assessories Digital Camera, Flat-Bed
  Scanner, Color Printer, Power Conditioner/UPS
• POTS Modem Connectivity

25
PHASE II - BI-DIRECTIONAL TELERADIOLOGYWith
WAVELETTE COMPRESSION ON-THE-FLY

• Phase II - Bi-directional Teleradiology
  Connectivity via between PACS and 10
  Physician-Provider Sites
• Funded through Project AKAMAI and the
• Alaska Federal Healthcare Partnership
• 1.4 Million, One-Time Appropriation
• Self Maintenance Plan
• Compatible with other AFHP sites

26
PHASE II - TELERADIOLOGY COUNTRY

• Phase II - Wide-Area PACS
  
  
  
  
  Bi-directional Connectivity
• Locations
• Barrow Ketchikan
• Bethel Kodiak
• Dillingham Kotzebue
• Fairbanks Nome
• Juneau Sitka

27
PHASE II - TELERAD SITE COMPONENTS

• X-Ray Film Digitizer
• Digitizer Compression
• Send Unit
• Frame Grabber
• Compression Send Unit
• DICOM Bridge
• Compression Send Unit
• Medium Resolution Dual-Monitor Reading Station
• Frame-Relay (56kbps) WAN Connectivity

28
Evaluation of System
ALASKA TELEMEDICINE PROJECT
____

- Human Factors Analyses - Staff
Turnover/Retention Analyses - Provider/Customer
Satisfaction - Utilization Review Analyses -
Cost-Benefit/Sustainability Analyses - Profile /
Cluster Analyses
NEEDS STUDY WHAT HAPPENS
EVALUATION ASSESSMENT PUBLISH FINDINGS
PROCESS
29
Conclusions

• Nearly 50 of telemed workstations built and
  being delivered to villages
• Teleradiology systems in place
• Evaluations will begin soon
• Provider
• Patient
• Clinical efficacy
• Business case

30
Questions?
31
Show 3- Minute Video Now Please
32
Referral Paradigm
I need text
I need to

• HUB
• SPOKE
• NEEDLE

33
Clinical Technical Issues - TELEMEDICINE (
N E E D L E P E R S P E C T I V E )
34
TELEMED NEEDLE Certified Health Aide
/ Professional (CHA/P) at Village Health Clinic

• PERSPECTIVE
• Convinced Telemed is an Important Tool
• Excited
• Overwhelmed
• Want Hub, Spoke Needle Contacts
• Want Call Coverage

• CONCERNS
• Not be Taken for Granted or Left Out
• Rather See Resources Spent on Other Things
• Worried about Fewer Med-Evacs
• Some Acute Cases

35
TELEMED NEEDLE Mid-Level Provider (PAs or CNPs)
at Sub-Regional Clinic

• PERSPECTIVE
• Motivated
• Want Hub, Spoke, Needle Contacts
• Improve Communication
• Diagnostic Tool
• Management Tool

• CONCERNS
• Adequate Training
• Electronic Forms Capability
• Call Coverage
• Technical Support

36
Clinical Technical Issues - TELEMEDICINE
TELERADIOLOGY( S P O K E P E R S P E C T I V
E )
37
TELEMED SPOKE Physician Provider at Regional
Hospital

• PERSPECTIVE
• 50/50 Acceptance
• Want Hub Contacts to Specialists
• Access to Competition
• Training Tool
• Want Regional Support

• CONCERNS
• Call-Back Nuisance
• Changing Referral Patterns
• Bypassing Present System
• Protocols

38
TELERAD SPOKE Rad Technologist at Regional
Hospital

• PERSPECTIVE
• Motivated
• Like Original Films to Stay in Department
• Emergency Reports-1H
• Report Time doesnt Depend on Mail - 24 Hr

• CONCERNS
• More Clerical Work
• Computer Phobia
• Loss of Data / Glitches
• Slow Transmission Times
• Technical Support

39
TELERAD SPOKE Physician at Regional Hospital

• PERSPECTIVE
• Interested / Skeptical
• Want Clinical Quality - Medium Resolution
• Emergency Reports-1H
• Interpretation - 24 Hr
• Permits Pulling Previous Exams

• CONCERNS
• Easy User Interface
• Still Like Looking at Film
• Fast Send Rates - Compression
• Technical Support

40
Clinical Technical Issues - TELEMEDICINE
TELERADIOLOGY( H U B P E R S P E C T I V E )
41
TELEMED HUB Physician Specialist at Referral
Hospital

• PERSPECTIVE
• Reluctance
• Follow-Up Tool
• Prefer High-Bandwidth Technology
• Lower-48 Contact with Specialists

• CONCERNS
• Call-Back Nuisance
• Changing Referral Patterns
• Bypassing Present System
• Protocols

42
TELERAD HUB Radiologist at Referral Hospital

• PERSPECTIVE
• Interested / Skeptical
• Want Diagnostic Quality - Hi-Res, Hi-Bw without
  Compression Losses
• Pre/Post Fetch Capability

• CONCERNS
• Too Much Work
• Up-Time
• Easy User Interface
• Competition Bypass
• No Two Radiologists Reading Same Study
• Buy-In at All Levels

43
PHASE III - TELERADIOLOGY NEEDLES

• Phase III - Teleradiology
  
  
  
  
  Unidirectional Connectivity via
  Teleradiology to 27
  
  
  
  Mid-Level
  Provider Sites
• Funding ???
• 2-3 Million, One-Time Appropriation
• Self Maintenance Plan
• Compatible with other AFHP sites

44
PHASE III - SITE COMPONENTS

• X-Ray Film Digitizer
• Digitizer Compression Send Unit
• POTS Modem Connection

45
Alaska Federal Healthcare Partnership
PACS/Teleradiology Plan
I need text here
46
PHASE III - TAKING LOW-BANDWIDTH
TELEMEDICINE STATE-WIDE

• Phase III - Telemedicine Implementation
  
  
  
  
  Plan for 235 Sites
• Alaska Federal Health Care Access Network -
• (AFHCAN Project )
• Major portion of Funded by special
  appropriation from Congress, through the Indian
  Health Service
• 30 Million over 4 Years
• Self Maintenance Plan
• Compatible with other NLM sites

47
PHASE III - AFHCAN TELEMED SITE COMPONENTS

• 688 Telemed Workstations
• NLM-Compatible Stations
• Full Compliment of Scopes
• Otoscope/Ophthalmoscope
• Dental Scope
• Derm Scope
• Culposcope
• 254 Telehealth Information Kiosks
• Satellite WAN Connectivity

48
AFHCAN PROJECT - ORGANIZATION/IMPLEMENTATION
COMMITTEE MODEL
49
I need text to cover up
Alaska Federal Healthcare Partnership AFHCAN
Project Telemedicine Sites

• Phase III Vision
• Useful,
• Compatible
• Telemedicine
• Technology
• for Every
• Provider
• Improved
• Access to
• Quality
• Care for
• Every
• Patient

50
- THE END -Credits for making this presentation
possible go to the following individuals

• Paul Sherry, CEO - ANHC
• Richard Madsager, MD - ANMC Director
• Russell Pittman, CIO - ANMC ITS
• Rich Hall - ANMC ITS
• Fred Pearce, PhD - UAA
• Rob Rauls, PO - ANHB
• Stuart Ferguson, PhD - ANHB
• Denise Statz, PA - ANHB

• Chuck Borg - AFHCP
• Susan Yeager - AFHCP
• Victorie Heart - CHA/P
• John Midthun, MD - ANMC Imaging Services
• Gwen Obermiller, RN - ANMC
  Administration
• Eugene Smith - Maniilaq
• Cheryl Booth, CHP - Noatak
• Ralph Schaber, RT - Dillingham

51
PHASE I - TELEMEDICINE
ALASKA TELEMEDICINE PROJECT
PHASE 1 PHASE 1
____

NEEDS EVALU- ASSESSMENT

ATION
52
PHASE IIa - TELEMEDICINE
ALASKA TELEMEDICINE PROJECT
PHASE 1 PHASE 2
PHASE 1
____

- Full-Motion Video Teleconference -
Narrow-Bandwidth VTC - Store Forward Voice
Video - Telemetry Teleradiology - Tele-Health
Informatics - E-Mail for every Health Provider
NEEDS DEMONSTRATIONS...
EVALU- ASSESSMENT
ATION

53
PHASE IIb - TELEMEDICINE
ALASKA TELEMEDICINE PROJECT
PHASE 1 PHASE 2
PHASE 2
____

- Human Factors Analyses - Staff
Turnover/Retention Analyses - Provider/Customer
Satisfaction - Utilization Review Analyses -
Cost-Benefit/Sustainability Analyses - Profile /
Cluster Analyses
NEEDS STUDY WHAT HAPPENS
EVALUATION ASSESSMENT PUBLISH FINDINGS
PROCESS
54
PHASE III - TELEMEDICINE
ALASKA TELEMEDICINE PROJECT
PHASE 1 PHASE 2
PHASE 1
PHASE 3
____


- Full-Motion Video Teleconference -
Narrow-Bandwidth VTC - Store Forward Voice
Video - Telemetry Teleradiology - Tele-Health
Informatics - E-Mail for every Health Provider
NEEDS DEMONSTRATIONS...
EVALU- IMPLEMEN- ASSESSMENT

ATION TATION