Making It Work:

1. Engineers Enhance Healthcare Delivery though Telemedicine and Teleradiology Making It Work: 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 • > $40 M /Yr

12. New Technologies-Handheld Examination Deivces

13. New Technologies-Imaging Devices

14. New Technologies

16. Telemedicine Workstation Assembly Line

17. I need text Alaska Native Health System 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. I need text Referral Paradigm I need to • HUB • SPOKE • NEEDLE

33. Needle Spoke Hub Clinical & Technical Issues -TELEMEDICINE ( N E E D L E P E R S P E C T I V E )

34. 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: Certified Health Aide / Professional (CHA/P) at Village Health Clinic

35. 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-Level Provider (PAs or CNPs) at Sub-Regional Clinic

36. Needle Spoke Hub Clinical & Technical Issues -TELEMEDICINE & TELERADIOLOGY( S P O K E P E R S P E C T I V E )

37. 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: Physician Provider at Regional Hospital

38. 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 Technologist at Regional Hospital

39. 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: Physician at Regional Hospital

40. Needle Spoke Hub Clinical & Technical Issues -TELEMEDICINE & TELERADIOLOGY( H U B P E R S P E C T I V E )

41. 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 Specialist at Referral Hospital

42. 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: Radiologist at Referral Hospital

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. I need text here Alaska Federal Healthcare PartnershipPACS/Teleradiology Plan

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. JOINT STEERING BOARD TECHNICAL CLINICAL PROJECT OFFICE TRAINING LEGAL INFORMATION BUSINESS AFHCAN PROJECT -ORGANIZATION/IMPLEMENTATION COMMITTEE MODEL:

49. I need text to cover up Alaska Federal Healthcare PartnershipAFHCAN Project Telemedicine Sites Phase III Vision: • Useful, • Compatible • Telemedicine • Technology • for Every • Provider • Improved • Access to • Quality • Care for • Every • Patient

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