Outcomes and Impacts of

The AFHCAN Telehealth ProgramStewart Ferguson, PhD

Chief Information Officer (CIO)Alaska Native Tribal Health Consortium

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.

2

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

Savoonga to Anchorage

$1000

Nuiqsut to Anchorage

$1100

Chevak to Anchorage

$950

Old Harbor to Anchorage

$1350

Point Hope to Anchorage

$980

AFHCAN MISSION

To improve access to health care for federal

beneficiaries in Alaska through sustainable

telehealth systems

Alaska

Federal

Health

Care

Access

Network

5

Store & Forward vs Real-Time Telehealth

Store & Forward

• Asynchronous Interaction

• Documents & Images

• Electronic Medical Records

• Patient Education

• Radiology

• Dermatology

• Pathology

• Oncology

• Ophthalmology

• Dental

• Cardiology

• ENT

• GI

• Pulmonary

• Rheumatology

• Psychology/ Psychiatry

• Neurology

• Speech therapy

• Physical therapy

Clinical specialties for telemedicine

• Face-to-Face Interaction

• Immediate Feedback

Remoteconsultation

Real-Time (VtC)

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

6

11 year Operational History◦ 33,000 cases / year

Whole Telehealth Solution◦ Design Manufacturing Deployment Installation Training Support Marketing

7

Installed Customer base includes:◦ Alaska: 248 sites, 44 organizations 37 Tribal organizations

US Army sites (6) & US Air Force bases (3)

State of Alaska Public Health Nursing (26)

◦ 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

Cas

es

Cre

ate

d

Cases Created per Year (by Role)

Primary Care Specialty Care

ATHS (Alaska Tribal Health System)

1/1/2001 to 12/31/2011

(126,666 Cases)

OUTCOMES

9

Physician’s surveyed at the point of care … on a per-case basis.

10All Alaska Servers (1/1/2001 to 12/31/2011)

0%10%20%30%40%50%60%70%80%90%

100%

% C

ase

s

Travel PREVENTED (by Case Role)

Primary Care Specialty Care

11All Alaska Servers (1/1/2001 to 12/31/2011)

$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

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

12

Note: For every $1 spent by Medicaid on reimbursement, $10.54 is saved on travel costs.

The value of using outreach clinics saved another $3.4m in travel costs

We only assume patients travel to nearest region

0

200

400

600

800

1,000

1,200

2003 2004 2005 2006 2007 2008 2009

Day

s

Preventing Lost Work/School Days

Work Days School Days

Since 2003, telehealth prevented an estimated 4,777

lost days at work (at a cost to Medicaid of $56.49 per

work day saved) and a total of 1,444 lost days at

school for the patients in this study.

15

GOALS FOR TELEMEDICINE

1.7

2.8

3.1

4.1

4.6

5.3

1 2 3 4 5 6

Cost of Care/Saving

Information Transfer

Continuity of Care

Patient Satisfaction

Access to Care

Quality of Care

Lesser Priority Average Priority Higher Priority

Patient

VisitsCost

Traveling Audiologist Program 1,987 ($175,000)

Patient Travel PreventedBased on Outcomes of:

• Did patient still need to travel to field clinic?

Assumptions:

• Only travel to hub is being saved.

• Escort required if patient less than 18 years old

• No lodging / per diem calculated

1,726

Note: 1,153

less than

18 yrs old

$697,090

Net Savings in Travel Costs

Realized by Program

$522,090(300% ROI)

26% 26%

19%

13%

27%

6%

Unnecessary &

cases were archived without

sending

Referred for

monitoringMeds started Referred to

regional ENT clinic

Surgery or

testing recommended

at ANMC

Refer to other

specialty

Note1: 1,987 patients

About 72% of the patients seen needed something done (meds, surgery, ongoing

monitoring) and 26% needed to be screened out.

Note2: Percentages may not add to 100% due to multiple outcomes per case.

19

PLAN

DO

ACT

STUDY

Deployment of the IHS-JVN in Alaska using a portable

platform reversed a seven year decline in rates for the state

0%

10%

20%

30%

40%

50%

60%

70%

DR

Exam

Rate

15% Increase

25% Decrease Portable JVN

implemented

21

Greater Efficiency of Existing Resources

22

Data courtesy of Phil Hofstetter

0

1

2

3

4

5

6

7

8

Ave

rage

Wai

t Ti

me

(m

on

ths)

Pre-Telemedicine Telemedicine

Theoretical Limit

23Data 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)

Pe

rce

nt

Ap

po

intm

en

t A

vaila

bil

ity

Wit

h 5

M

on

th o

r Lo

nge

r W

ait

Tim

e

Access

$0

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

$140,000

$160,000

$180,000

$200,000

0

100

200

300

400

500

600

700

1999 2000 2001 2002 2003 2004 2005 2006

Co

st S

avin

gs

Re

ferr

als

to S

pe

cia

lty

Clin

ic

Year

Referrals to Specialty Clinic

Telemed Consults

NSHC cost Savings

Travel Savings

Data courtesy of Phil Hofstetter

25

26All Alaska Servers (1/1/2001 to 12/31/2011)

0% 20% 40% 60% 80% 100%

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

ANMC Turnaround Time

Within 60 min.

Same Day

Within 24hrs

20% of all specialty consultations are turned around in 60 minutes.

50%-60% are turned around in the same day.

70%-80% are turned around within 24 hours.

• Speed of response is clearly more important to Initiators compared to Consultant

• High User Initiators - 43% rated this 5 out of 5 (“Extremely Important”)

27

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

High User (Initiator) High User (Consultant) Medium User (Initiator) Medium User

(Consultant)

When using AFHCAN for patient care – how important is

the speed of reply of the consulting doctor?

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

Pe

rce

nt

of P

atie

nts

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

TTAC 29

TTAC

Educational content on the TTAC website◦ Point-and-Shoot Digital Cameras◦ Desktop Videoconferencing Software◦ Patient Exam Cameras◦ Electronic Stethoscopes◦ Technology Assessment 101◦ Video Otoscopes◦ Home Health◦ Videoconferencing Endpoints◦ Videoconferencing Bridges◦ Digital SLR Cameras (2012)◦ mHealth (2012)◦ Portable Ultrasound (2012)

31

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Cas

es

Cre

ate

d

Cases Created per Year

… would be considered in a “telemedicine” priority situation …”

33All Alaska Servers (1/1/2001 to 12/31/2011)

0

200

400

600

800

1,000

1,200

1,400

1,600

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

# P

rovi

de

rsAnnual Provider Usage

(by Experience)

Return New

Course I: Understanding Telehealth & the Role of the Telehealth Coordinator◦ Topics include telehealth applications, specialty uses,

rural impact, case management, business aspects, etc.

Course II: Becoming a Certified Telehealth Coordinator◦ Provides attendees the tools & skills needed to support

the use of telehealth

Course III: Becoming a Certified Telehealth Program Manager◦ Provides attendees the tools & skills needed to manage

telehealth programs

HTM Deployed Sites

HTM is in 58 Communities

AFHCP HTM Program

Deployed Sites

Home Telehealth Monitoring – 950 patients

Statewide Pediatric Subspecialty Program◦ Expert Mentoring

Palliative Care (End of Life, Chronic Care)◦ JIT (Just in Time) Training

Expert Triage Model

Travelling Providers

Workforce Development◦ Dental Health Aide Therapists

◦ Rural Telehealth Coordinators

Explore new payment models

36

Health Care Innovation Challenge

Center for Medicare & Medicaid Innovation

Higher Quality

Lower Cost

0

5,000

10,000

15,000

20,000

25,000

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Cas

es

Cre

ate

d

Cases Created per Year (by Role)

Specialty Care Internal Use

10 Years Ago◦ “Should we do telemedicine”

◦ “Will patients be satisfied”

◦ “How do we do telemedicine”

Now◦ “How do we integrate telehealth with the care

environment”

◦ “How can we support and expand telehealth capability”

37

38

Purpose: form a professional society for telemedicine that will provide:◦ A public, statewide common voice

◦ A collaborative, non-competitive environment for networking and education

◦ Increased public, health care sector and legislative awareness

Telehealth in Alaska is in a state of flux –growing but not necessarily fully “integrated”◦ Many specialties remain to be engaged

◦ Statewide capability for broadband telehealth is under-utilized

Customers are recognizing options◦ Care is becoming more available, more immediate,

at a lower cost, with less difficulty

Younger providers will bring an enabling attitude and experience

Health Information Exchange is “expected”

40

GOALS FOR TELEMEDICINE

1.7

2.8

3.1

4.1

4.6

5.3

1 2 3 4 5 6

Cost of Care/Saving

Information Transfer

Continuity of Care

Patient Satisfaction

Access to Care

Quality of Care

Lesser Priority Average Priority Higher Priority

42

• Best for patient care

• Increased access for care

• Saves my organization money

• Improves patient satisfaction

0% 10% 20% 30% 40% 50% 60% 70%

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 …

Increase access to care

High Users 29Medium Users 23

Low Users 51

Thank You

AFHCAN, Alaska Native Tribal Health Consortium, Anchorage, AK

Stewart Ferguson, PhD

Alaska Federal Health Care Access Network (AFHCAN)

Alaska Native Tribal Health Consortium

4000 Ambassador Drive

Anchorage, AK 99508

(907) 729-2262

sferguson@anthc.org

44