PACMEDTek - 1998Clinical ApplicationsDenver Allen Lodge, M.E., CCEChief Biomedical/Clinical EngineerAlaska Area Native Health Service

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Telemedicine and Telemedicine and TeleradiologyTeleradiology

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Alaska Native Health Alaska Native Health SystemSystem

• Alaska Native Medical CenterAlaska Native Medical Center• 7 Regional Hospitals7 Regional Hospitals• 5 Physician-Based 5 Physician-Based Health CentersHealth Centers• 22 Physician 22 Physician AssistantAssistant Health CentersHealth Centers• 168 Rural Village168 Rural Village Health StationsHealth Stations

Village Health Village Health ClinicsClinics

• 168 Rememote Locationsote Locations• Staff: 450 CHA/Ps450 CHA/Ps• 300,000 OPE/Yr00 OPE/Yr• $3M Equipmentquipment

Alaska Native Medical Alaska Native Medical CenterCenter

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

Patient TransportationPatient Transportation

• 90,000 Med-Evacs/Yred-Evacs/Yr• > $40 M / YrYr

Telecommunications Telecommunications InfrastructureInfrastructure• Satellite Only (Low-

Bandwidth)• POTS Modem 9600

bps• Frame Relay 56Kbps

____}{ PHASE 1 PHASE 1

ALASKATELEMEDICINEPROJECT

NEEDS EVALU- ASSESSMENT ATION

PHASE I - PHASE I - TELEMEDICINE TELEMEDICINE

____}- Full-Motion Video Teleconference- Narrow-Bandwidth VTC- Store & Forward Voice & Video- Telemetry & Teleradiology - Tele-Health Informatics- E-Mail for every Health Provider{

PHASE 1 PHASE 2 PHASE 1

ALASKATELEMEDICINEPROJECT

NEEDS DEMONSTRATIONS... EVALU- ASSESSMENT ATION

PHASE IIa - PHASE IIa - TELEMEDICINETELEMEDICINE

____}- Human Factors Analyses- Staff Turnover/Retention Analyses- Provider/Customer Satisfaction - Utilization Review Analyses- Cost-Benefit/Sustainability Analyses- Profile / Cluster Analyses{

PHASE 1 PHASE 2 PHASE 2

ALASKATELEMEDICINEPROJECT

NEEDS STUDY WHAT HAPPENS EVALUATIONASSESSMENT & PUBLISH FINDINGS PROCESS

PHASE IIb - PHASE IIb - TELEMEDICINETELEMEDICINE

____}- Full-Motion Video Teleconference- Narrow-Bandwidth VTC- Store & Forward Voice & Video- Telemetry & Teleradiology - Tele-Health Informatics- E-Mail for every Health Provider{

PHASE 1 PHASE 2 PHASE 1 PHASE 3

ALASKATELEMEDICINEPROJECT

NEEDS DEMONSTRATIONS... EVALU- IMPLEMEN-ASSESSMENT ATION TATION

$

PHASE III - PHASE III - TELEMEDICINETELEMEDICINE

• Phase I - Needs Assessment performed by Alaska Native Health Board (ANHB)

• 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

PHASE I - PHASE I - TELEMED TELEMED

BASELINE RESEARCHBASELINE RESEARCH

• 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

PHASE I -PHASE I - TELERAD PILOT TELERAD PILOT

PROJECTPROJECT

• Phase II - ANHB Needs Assessment yields NLM / UAA Evaluation Focus on Telemedicine Treatment of Ear Pathology

• $ Phase II also Funded by NLM Contract

PHASE II -PHASE II - SCOPE OF SCOPE OF TELEMED EVALUATIONTELEMED EVALUATION

• 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

PHASE II -PHASE II - TELEMEDICINE TELEMEDICINE COUNTRYCOUNTRY

PHASE II - PHASE II - LOW-LOW-BANDWIDTH TELEMEDBANDWIDTH TELEMED

SITE SITE COMPONENTSCOMPONENTS

• 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

• 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

PHASE II - PHASE II - BI-DIRECTIONAL BI-DIRECTIONAL TELERADIOLOGYTELERADIOLOGYWith WAVELETTE COMPRESSION With WAVELETTE COMPRESSION ON-THE-FLYON-THE-FLY

• Phase II - Wide-Area PACS Bi-directional Connectivity

Locations:

• Barrow – Ketchikan• Bethel – Kodiak• Dillingham – Kotzebue• Fairbanks – Nome• Juneau – Sitka

PHASE II - PHASE II - TELERADIOLOGY COUNTRYTELERADIOLOGY COUNTRY

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

Show 3- Minute Video Show 3- Minute Video Now PleaseNow Please

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• HUBHUB• SPOKESPOKE• NEEDLENEEDLE

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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

TELEMED NEEDLE: TELEMED NEEDLE: Certified Health Certified Health Aide / Professional Aide / Professional (CHA/P) at Village Health (CHA/P) at Village Health ClinicClinic

PERSPECTIVE:• Motivated• Want Hub, Spoke,

& Needle Contacts• Improve

Communication• Diagnostic Tool• Management Tool

CONCERNS:• Adequate Training• Electronic Forms

Capability • Call Coverage• Technical Support

TELEMED NEEDLE: Mid-TELEMED NEEDLE: Mid-Level Provider (PAs or Level Provider (PAs or CNPs) at Sub-Regional CNPs) at Sub-Regional ClinicClinic

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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

TELEMED SPOKE: TELEMED SPOKE: Physician Provider Physician Provider at Regional Hospitalat Regional Hospital

PERSPECTIVE:• Motivated• Like Original Films

to Stay in Department

• Emergency Reports-1H

• Report Time doesn’t Depend on Mail - 24 Hr

CONCERNS:• More Clerical Work• Computer Phobia• Loss of Data /

Glitches• Slow Transmission

Times• Technical Support

TELERAD SPOKE: Rad TELERAD SPOKE: Rad Technologist at Regional Technologist at Regional HospitalHospital

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

TELERAD SPOKE: TELERAD SPOKE: Physician at Regional Physician at Regional HospitalHospital

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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

TELEMED HUB: Physician TELEMED HUB: Physician Specialist Specialist at Referral Hospitalat 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

TELERAD HUB: TELERAD HUB: Radiologist at Radiologist at Referral HospitalReferral Hospital

• 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

PHASE III - PHASE III - TELERADIOLOGY NEEDLESTELERADIOLOGY NEEDLES

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

PHASE III - PHASE III - SITE SITE COMPONENTSCOMPONENTS

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Alaska Federal Healthcare Partnership

PACS/Teleradiology Plan

• 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

PHASE III -PHASE III - TAKING TAKING LOW-BANDWIDTHLOW-BANDWIDTH

TELEMEDICINE TELEMEDICINE STATE-WIDESTATE-WIDE

PHASE III -PHASE III - AFHCAN AFHCAN TELEMED TELEMED SITE COMPONENTSSITE 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

AFHCAN PROJECT -AFHCAN PROJECT - ORGANIZATION/IMPLEMENTATIOORGANIZATION/IMPLEMENTATION COMMITTEE MODEL:N COMMITTEE MODEL:

JOINT STEERING BOARD

TECHNICAL

TRAININGPROJECTOFFICE

INFORMATION

CLINICAL

LEGAL

BUSINESS

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Alaska Federal Healthcare Alaska Federal Healthcare PartnershipPartnership

AFHCAN Project Telemedicine Sites

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

- THE END -- 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