The IHS Telehealth Program:Innovation and ROI Mark Carroll, MD

Overview of IHS and Indian health care

Highlights specific to the IHS Telehealth Program

Thoughts and possibilities re: strategic collaboration with the Northwest Regional Telehealth Resource Center

Objectives for this presentation

INDIAN HEALTH SERVICEMISSION, GOAL, & FOUNDATION

The The MissionMission, in partnership with American Indian and Alaska , in partnership with American Indian and Alaska Native people, is to raise their physical, mental, social and Native people, is to raise their physical, mental, social and spiritual health to the highest level.spiritual health to the highest level.

The The GoalGoal is to ensure that comprehensive, culturally acceptable is to ensure that comprehensive, culturally acceptable personal and public health services are available and accessible personal and public health services are available and accessible to all American Indian and Alaska Native people.to all American Indian and Alaska Native people.

The The FoundationFoundation is to uphold the Federal Government’s obligation is to uphold the Federal Government’s obligation to promote healthy American Indian and Alaska Native people, to promote healthy American Indian and Alaska Native people, communities and cultures, and to honor and protect the inherent communities and cultures, and to honor and protect the inherent sovereign rights of Tribes.sovereign rights of Tribes.

Provides a comprehensive health service delivery Provides a comprehensive health service delivery system for approximately system for approximately 1.9 million of 3.3 million 1.9 million of 3.3 million American Indians and Alaska Natives. American Indians and Alaska Natives.

Serves members of Serves members of 561 federally recognized Tribes561 federally recognized Tribes in in 35 states.35 states.

FY 2007 appropriation is approximately $3.2 billion. FY 2007 appropriation is approximately $3.2 billion.

Indian Health Service total staff consists of about Indian Health Service total staff consists of about 15, 15, 850 employees850 employees, which includes approximately 2,600 , which includes approximately 2,600 nurses, 930 physicians, 390 engineers, 500 nurses, 930 physicians, 390 engineers, 500 pharmacists, 300 dentists, and 170 sanitarians pharmacists, 300 dentists, and 170 sanitarians

A Quick Look at theINDIAN HEALTH SERVICE

Partnership with Partnership with Tribal GovernmentsTribal Governments

The Indian Self-Determination Act of 1975 includes an opportunity for Tribes to assume the responsibility of providing health care for their members, without lessening any Federal treaty obligation.

Tribes now administer health care contracts and compacts with the IHS valued at over $1.5 billion. This represents approximately 54% of the IHS budget authority appropriation.

163 Service Units in 12 163 Service Units in 12 Areas Located in 35 StatesAreas Located in 35 States

Indian Health Care SystemsIndian Health Care Systems

Source: IHS Regional Differences, 2000-2001Source: IHS Regional Differences, 2000-2001

HospitalsHospitals Health Health Centers Centers

Alaska Village Clinics Alaska Village Clinics Health Health Stations Stations

IHS 33 54 N/A 38Tribal 15 229 162 116

The IHS also supports 34 Urban Clinics across the The IHS also supports 34 Urban Clinics across the nation.nation.

IHS Hospital SystemIHS Hospital System

JCAHO AccreditedJCAHO Accredited

Size varies: Size varies:

156 Beds - 6 Beds156 Beds - 6 Beds

59,000 Admissions 59,000 Admissions per year per year (2006)(2006)

9,797,000 Outpatient 9,797,000 Outpatient visits per year visits per year (2006)(2006)

Rural Primary Care System – Rural Primary Care System – with some Urban Locationswith some Urban Locations

Hospital

Ambulatory Center

60% of IHS 60% of IHS hospitals and hospitals and ambulatory ambulatory centerscenters are in are in remote areasremote areas

Community Oriented Community Oriented ProgramsPrograms

Community Community oriented primary oriented primary carecare

Public health Public health emphasisemphasis

Traveling services Traveling services in remote villagesin remote villages

Community health Community health representativesrepresentatives

Village health aidsVillage health aids

Community & Community & school health school health educationeducation

Traveling dental team visits remote Traveling dental team visits remote villages in Alaskavillages in Alaska

IHS Constructs Community Water IHS Constructs Community Water Supply & Waste Disposal FacilitiesSupply & Waste Disposal Facilities

WHAT ABOUT RESULTS?WHAT ABOUT RESULTS?

Source: IHS/OPHS/DPS, June 2005 13

Mortality Rates for Indian People Mortality Rates for Indian People Have Declined Since 1973Have Declined Since 1973

80.4

76.3

66.0

64.1

59.6

57.1

45.7

39.7

38.7

16.8

0 20 40 60 80 100

Tuberculosis

Cervical Cancer

Infant Deaths

Maternal Deaths

Accidental

Homicide

Alcohol-Related

Cerebrovascular

Pneumonia & Influenza

Suicide

Percent Decrease in Mortality Rates(Adjusted for misreporting of AI/AN race on State death certificates.)

CY 2000-2002CY 2000-2002

U.S.U.S. Ratio:Ratio: AI/ANAI/AN All RacesAll Races AI/ANAI/AN RateRate RateRate to U.S. to U.S. 2001- 20032001- 2003 20022002 All RacesAll Races

MORTALITY RATE DISPARITIES MORTALITY RATE DISPARITIES CONTINUE CONTINUE

American Indians and Alaska Natives in the IHS Service Area2001-2003

(Age-adjusted mortality rates per 100,000 population)

ALL CAUSESALL CAUSES 1042.2 845.3 1042.2 845.3 1.21.2 TuberculosisTuberculosis 1.81.8 0.3 0.3 6.06.0 AlcoholismAlcoholism 43.643.6 6.7 6.7 6.56.5 DiabetesDiabetes 75.275.2 25.425.4 3.03.0 Motor vehicle crashesMotor vehicle crashes 51.151.1 15.715.7 3.33.3 Unintentional Injuries Unintentional Injuries 93.8 93.8 36.9 36.9 2.5 2.5 HomicideHomicide 12.712.7 6.1 6.1 2.12.1 SuicideSuicide 17.117.1 10.910.9 1.61.6 Cervical cancerCervical cancer 4.44.4 2.6 2.6 1.71.7 Infant deaths Infant deaths 1/1/ 9.89.8 7.0 7.0 1.41.4 Cerebrovascular diseasesCerebrovascular diseases 54.754.7 56.256.2 1.01.0 1/ Infant deaths per 1,000 live births

NOTE: American Indian and Alaska Native (AI/AN) rates were adjusted to compensate for misreporting of AI/AN race on state death certificates. AI/AN rates are based on 2000 census with bridged-race categories developed by the Census Bureau and the National Center for Health Statistics. Jan. 2007

Suicide RatesSuicide Rates Ages 15-19, by Race and GenderAges 15-19, by Race and Gender

Rates per 100,000 peopleRates per 100,000 people Source: CDC/2000

0

5

10

15

20

25

30

35

All White Black American

Indian/

Alaska

Native

Asian

AmericanHispanic

MaleFemale

0

5

10

15

20

Year

Per

cen

t

AIAN

US

Source: IHS Program Statistics and National Diabetes Surveillance System.

1980- 20041980- 2004

Prevalence of Diagnosed Diabetes:Prevalence of Diagnosed Diabetes:AI/ANs Compared to U.S. PopulationAI/ANs Compared to U.S. Population

Per Capita Expenditures Trend:Per Capita Expenditures Trend:IHS Compared to US AverageIHS Compared to US Average

$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

$3,500

$4,000

$4,500

$5,000

$5,500

$6,000

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

IHS Per Capita Expenditure

US Per Capita Expenditure

*for personal health care services

To improve service delivery in the face of: Increasing service population/need Disparities in:

Mortality dataFundingStaffingFacilities

Telehealth as a Business Tool

Indian Health Service and Indian Health Service and Health Information TechnologyHealth Information Technology

Improve health care access, Improve health care access, quality, transparency, and quality, transparency, and valuevalue

Highlight the vital Highlight the vital perspectives and priorities of perspectives and priorities of communities, as well as communities, as well as populations populations

Involve the input of our “key Involve the input of our “key stakeholders” - the American stakeholders” - the American Indian and Alaska Native Indian and Alaska Native peoplepeople

Emphasis on Emerging Tools Emphasis on Emerging Tools that:that:

What are the opportunities for shared/collaborative service delivery? To help improve

Acess to quality careValue

What are the opportunities specific to chronic care? Specialist care Care coordination/remote monitoring

Key Questions for Telehealth

IHS Telehealth Directory - 2005

National directory work done in 2005 Foundation for

targeting collaboration opportunities with IHS Areas within NRTRC ‘catchment’

All IHS Areas had active clinical telehealth underway In over 30 clinical

disciplines

Area

Telehealth Modality

By Area

Ab

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Ala

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Anesthesiology ● Cardiology ● ● ● ● ● ● ●

Child Abuse (IHS/OVCProgram)

● ● ● ● ● ● ● ●

Dental ● ● ● Dermatology ● ● ● ● ● ● ● ●

Endocrinology ● ● ● ENT ● ● ● ● ● e-ED ● ● ●

GI ● Geriatrics ●

HIV ● Mental Health ● ● ● ● ● ● ● ●

Nephrology ● ● Nuerology ● ● ● ●

Nutrition ● ● ● ● OB/GYN ● ●

Oncology ● ● Ophthalmology ● ● ●

IHS/JVN Teleoph ● ● ● ● ● ● ● ● ● ● ● Orthopedics ● ● ●

Pain ● ● Pediatrics ● ● Pharmacy ● ● ● ●

Pulmonology ● ● Radiology ● ● ● ● ● ● ● ●

Rehabilitation ● ● ● Rheumatology ● ●

Surgery ● ● ● ● Urology ●

Th

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Mo

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Wound Care ● ● ● ●

Telehealth Category Telehealth Modality

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IHS

/JV

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Area

ID Benewah Medical Ctr

● ●

Fort Hall Indian Health Center

● ●

Nimiipuu Health Clinic

● ●

OR

Warm Springs Health Center

● ●

WA Coleville Indian Health Clinic

● ●

Inchelium Tribal Clinic

●

Neah Bay Indian Health Center

● ●

Sanpol Tribal Clinic

●

Wynecoop Memorial Cl

● ●

Yakama Indian Hospital

● ●

● Planned

Po

rtla

nd

●* IHS-OVC Child Abuse Project

2005

Not updated since 2005

Telehealth Category Telehealth Modality

Are

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Area Area Office ●

MT

Browing Indian Hospital

●

●

Crow Agency Indian Hospital

● ● ● ●

Ft. Belknap Indian Health Center

● ●

Lame Deer Indian Health Center

● ●*

WY Ft. Washaskie Indian Health Center

● ●*

● Planned

Bill

ing

s

●* IHS-OVC Child Abuse Project

2005

Not updated since 2005

Collaborations are Key

Within Indian health Southwest Telehealth

Consortium Alaska Federal Health Care

Access Network (AFHCAN) Inter-Area “corporate” projects

With other federal agencies Veterans Health Administration

With universities, states, and other organizations

IHS Telehealth Program:Leveraging Investments

Build on existing successes

IHS Joslin Vision Network

Retinal screening and diagnostic tele-ophthalmology services for patients with diabetes

57 sites nationally in 15 states

Single reading center at Phoenix Indian Medical Center

Over 22,000 interpretations performed to date

IHS/JVN Teleophthalmology Program

2000 - 2007

Projecting 100 Deployments by end of FY 2009

183

10011262

1624

3027

5700

4545

3537

0

5000

10000

15000

20000

25000

2000 2001 2002 2003 2004 2005 2006 2007

Program Year

Cu

mu

lati

ve S

tud

ies

0

1000

2000

3000

4000

5000

6000

An

nu

al s

tud

ies

21,000 total studies

Going Mobile

Portable JVN Proof-of-concept to

the Artic Circle in 2006

AFHCAN Telehealth8 years operational historyR&D Telehealth System10,000 cases / yearManufacturing of Medical DevicesWhole Product Solution Design Installation Training Support Marketing

Installed Customer base includes: 248 sites, 44 organizations

• 37 Tribal organizations• US Army sites (6)• US Air Force bases (3)• State of Alaska Public Health Nursing (26)• US Coast Guard clinics (5)• US Coast Guard cutters and ice breakers (6)

IHS-AFHCAN Collaboration

National Telehealth Infrastructure in Indian Health Offer a secure

enterprise solution for store-and-forward telemedicine across Indian health

Multi-Modality “Store&Forward” T-Health

Telemedicine will improve the QUALITY OF CARE for this

patient. (n=1,681)

For this case, rate the following statement:

3%

0%

10%

41%

45%

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Product Evaluation

Server infrastructure IHS core network in place

Includes capability for outside, non-IHS consultants/specialists

Multiple Areas with AFHCAN serversNashville, Phoenix, Portland

Other Area capacity expandingSome via planned expansion of

tele-consultation support for IHS AIDS-HIV telemedicine project

AFHCAN Status Report - #1

Carts not required Lots of telemedicine possible via free

software + local PCs + peripherals (e.g. digital camera)

AFHCAN-RPMS interface 1st phase being completed

Service models developing for multiple sites from different Areas Note: Tremendous opportunity for

quality, value, and system efficiencies

AFHCAN Status Report - #2

Integrated Systems of Care

Focus on standards and information systems integration AFHCAN to be

integrated with - The IHS

Electronic Health Record

And VistA Imaging

Tele-Behavioral Health

Growing experience already within Indian health Growing need National Tele-

psychiatry consultant appointed

Possible funding increases in years ahead

Informed,Empowered Patient and

Family

Productive Interactions through effective asset based partnering over time

Prepared,ProactivePractice Team

Improved achievement of patient and community goals

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community

Health Care Organization

Care Model

Patient Driven Coordinated

Timely and Efficient

Evidence-based and Safe

Informed,Empowered Patient and

Family

Productive Interactions through effective asset based partnering over time

Prepared,ProactivePractice Team

Improved achievement of patient and community goals

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community

Health Care Organization

Care Model

Patient Driven Coordinated

Timely and Efficient

Evidence-based and Safe

1. Develop a multidisciplinary team that optimizes the role of each member in clinic & community

2. Optimize the Care Team: each member performs at the highest level of their licensure.

3. Focus on access, efficiencies and flow

4. Provide clinical case management services for complex patients

5. Give care that patients understand and that fits with cultural background

6. Think about alternative approaches to traditional 1:1 face to face care: telehealth, group visits, etc.

7. Integrate traditional medicine

VHA CCHT Patient Numbers

0

5000

10000

15000

20000

25000

FY 03 FY05 FY 06 FY 07

Number of Patients

As of 3/30/07 25,000 pts

HOME TELEHEALTH FORHEART FAILURE

HEARTHealth Enhancement for American Indians & Alaska Natives Through

Residential Telemedicine

‘Success with Failure’

Economics of Home Telehealth

Annualized cost per patient ~ $2,500 Includes cost of equipment and shared staff

(new) to oversee day-to-day program

Annualized savings per patient ~$30,000 Assumes prevention of roughly 1.5

hospitalizations per year for patients with heart failure as primary diagnosis

Savings in Hospitalization Costs by Effectiveness, 75 Patients Enrolled, 109 expected hospitalizations.

$-

$500,000.00

$1,000,000.00

$1,500,000.00

$2,000,000.00

$2,500,000.00

27 55 82 109

Effectiveness (Hospitalizations Prevented)

__S

avin

gs__

HospCost=$20,084

Note: Cost/Hospitalization from Dasta (2005) AHA 6th Scientific Forum on Quality ofCare and Outcomes Research in Cardiovascular Disease & Stroke

POTENTIAL SAVINGS

Home T-Health Reimbursement

System savings don’t equal individual facility budget savings Savings to 3rd party insurers vs.

individual facility CHS budget

And incentives are “malaligned” E.g. Decreased hospitalizations are not

advantageous to some referral facility operating budgets

Lapsed salaries Use T-health for unfilled vacancies

Reimbursement Relies on 3rd party payer policy and rates

Cost Avoidance Eg.For contract health budgets

Agreements/contracts Shared costs among facilities/communities

for specialist FTEs/services

T-Health Business Models

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

About 73% of the patients seen needed something done (meds, surgery, ongoing monitoring) and 27% needed to be screened out.

Alaska ENT Outcomes (n=897)

27%

22%19% 19%

23%

5%

Unnecessary &cases were

archivedwithout sending

Referred formonitoring

Meds started Referred toregional ENT

clinic

Surgery ortesting

recommendedat ANMC

Refer to otherspecialty

ENT Tele-Consultation Center

Specialists at Alaska Native Medical Center Statewide experience

via the AFHCAN network

Extended in 2006 to patients at the Yakima Indian Health facility in eastern Washington

Further extension in 2007-08 to other Indian health facilities outside Alaska “Expert triage” model

New Service Models Possible For:

Radiology

Retinopathy screening

Mental health

Dermatology

ENT

Cardiology

Pharmacy

AIDS-HIV care

Neurology

Nutrition/Dietetics

Telehealth Service “Menu”

Real-Time Store&Forward Home

Clinical Mental Health JVN Heart Failure Care

Cardiology Cardiology Diabetes Care

Rheumatology Rheumatology

Nutrition Services Dermatology

Pain Management Radiology

AIDS/HIV Care

ENT

Educational CME/Rounds Streaming Media

Pathways into Health

Programmatic Tele-Public Health

*Draft – Phoenix Area IHS* 2006

Phoenix Area IHS: 2007 Telehealth Services Available

Clinical Service Brief Description of Service

Tele-Retinal Surveillance

Diagnosis and management of diabetic eye disease via the IHS Joslin Vision Network (JVN) program

Tele-Cardiology Consultation

Consultation to primary teams from the Native American Cardiology Program for cardiovascular conditions

Tele-NutritionCare

Real-time videoconferencing between patients, families, and a certified dietician regarding nutrition services for chronic conditions

Tele-NephrologyConsultation

Consultation to primary care teams from Phoenix Area IHS adult and child nephrologists regarding kidney disorders

Home Telehealth for Heart Failure Care

Home-based care management from the Native American Cardiology Program for patients with heart failure

Tele-Behavioral Health Videoconferencing services for addiction medicine, pain management, and mental health counseling

Tele-Rheumatology Video and AFHCAN-based consultation from IHS rheumatologist

Tele-Geriatric Consultation

Consultation to primary care teams from the IHS Geriatrics consultant regarding medical care for elders

Tele-Radiology Radiology interpretations from Phoenix Indian Medical Center

Tele-Dermatology Consultation

Consultation to primary care teams from the Arizona Telemedicine Program dermatologist regarding skin conditions

IHS-NRTRC Collaboration

Possible Areas of Strategic Partnership Regional service

menu development Regional distance

education Target a specific

clinical service for the region?

Business modeling Dialogue with state

Medicaid programs Response to specific

questions and issues

Thank You