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A FIRST-HAND LOOK AT TELEHEALTH IN A PRIMARY HEALTH CARE CENTER. Terry Jean Yonker, RN, MS, FNP-BC Telemedicine Clinical Coordinator Finger Lakes Community & Migrant Health, Inc. Penn Yan, NY 14527 1-800-724-0862. Agenda for Our Presentation.

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a first hand look at telehealth in a primary health care center

A FIRST-HAND LOOK AT TELEHEALTH IN A PRIMARY HEALTH CARE CENTER

Terry Jean Yonker, RN, MS, FNP-BC

Telemedicine Clinical Coordinator

Finger Lakes Community & Migrant Health, Inc.

Penn Yan, NY 14527

1-800-724-0862

slide2
Agenda for Our Presentation

1. Discuss needs of underserved populations seen in primary care setting 2. discuss the role of telehealth in medical home3. discuss administrative, technical, and clinical processes needed for success4. observe telepresentation and use of peripherals to conduct remote exams5. participate in review of literature and clinical cases relevant to tele-ent, tele-mental health, tele-opthalmology,andteledentistry6. List opportunities for future telehealth applications in community and migrant health centers

slide3
Finger Lakes Community & Migrant Health

Mission Statement….to ensure accessible and affordable health care to the communities we serveMedical Home Concept…patient-centered approach whereby health care team works together to coordinate and support primary and preventive care for an individualCelebrate Diversity … a dedicated, culturally sensitive staff who are committed to high quality , comprehensive care and are Passionate about the work that they do501(c) (3), Article 28 Federally Qualified Health CentersMigrant Health 330g FundingMobile health servicesEnabling Services

slide5

FLMHCP CLINICS AND NEAREST METROPOLITAN CENTERS

35 miles

55 miles

50 miles

60 miles

110 miles

slide7
Challenges In Providing Health Care To Rural Poor

Culture beliefsLanguage differencestransportation barrierslack of Child careno insurancelack of trust in health care systempovertymigrant lifestyle

creative ways to provide care
Creative Ways to Provide Care

.

  • Bilingual/Bicultural Staff
  • Clinic Hours Conducive to Work Hours
  • Community Health Workers
  • Case Management
  • Passionate/Compassionate Staff
  • Visionary Leadership
  • One Stop Shopping (Medical Home)
  • Telemedicine
what is telemedicine
What is Telemedicine?

NYS Office of the Professions defines telemedicine as the provision of professional services over geographical distances by means of modern telecommunications technology.

what is telehealth
What is Telehealth?

Telehealth is the delivery of health-related services and information via telecommunications technologies.

Telehealth is an expansion of telemedicine that encompasses administrative or educational functions related to telemedicine.

.

american telemedicine association
American Telemedicine Association

Established in 1993 as a non-profit organization……….

The American Telemedicine Association is the leading international resource and advocate promoting the use of advanced remote medical technologies. ATA and its diverse membership, works to fully integrate telemedicine into transformed healthcare systems to improve quality, equity and affordability of healthcare throughout the world.

Vision Statement

Telemedicine will be fully integrated into transformed healthcare systems to improve quality, equity and affordability of healthcare throughout the world.

Mission Statement

The mission of ATA is to promote professional, ethical and equitable improvement in health care delivery through telecommunications and information technology. This will be achieved through the following means:

Educating and engaging government, payers and the public about telemedicine

Providing a clearinghouse of information and services for both newcomers and experienced professionals

Fostering networking and collaboration among allied interests in medicine and technology

Promoting research, innovation and education

Developing and disseminating policies and standards

Ensuring a strong financial basis for the association to support operations

Creating consumer awareness and support

  • National Headquarters
  • American Telemedicine Association 1100 Connecticut Avenue, NW, Suite 540 Washington, DC 20036 Phone: 202.223.3333 Fax: 202.223.2787 E-mail: info@americantelemed.org

www.americantelemed.org

applications of telemedicine
APPLICATIONS OF TELEMEDICINE
  • Teleradiology
  • Telepathology
  • Teledermatology
  • Wound care consults
  • Home Based Monitoring
  • Urgent Care Consults
  • Pre & Post Op Care
  • Specialty Care Consults
  • Teledentistry
  • Burn/Trauma
  • ED – Stroke Initiative
  • Telehome Healthcare
  • ICU Intensivist
  • Inpatient /Nursing Home Consults
  • Outpatient/ Primary Care
  • Telepsychiatry
  • Counseling
  • Preventive Screenings
  • Health Education
benefits of telehealth
Benefits of Telehealth

Patients/Families Providers Health Care System*reduced travel* *direct patient interaction* * improved access* *timely appointments* *expanded services* *improved health outcomes*

*remain in their community* *access to other experts* *resource utilization* *additional support* *access to CME* * expansion to rural &

underserved*

typical telemedicine system in our clinics
Typical Telemedicine System in Our Clinics

GeneralExam

Camera

Telephonic

Stethoscope

Video Codec with LCD Monitor

Electronic Medical

Record

(

EMR

)

Dental Intraoral

Camera

ENT Scope

slide16

Store and Forward vs. Real Time

Digital Images Videoconferencing

2 big r s
2 BIG “R”s
  • REGULATION
  • Licensure
  • Standards of Care
  • No substitute for in-person care
  • Confidentiality

REIMBURSEMENT

  • Medicare
  • Medicaid
  • Blues
  • Preferred Care
  • NP Office Visits
  • HIPPA Secure
how we started how we planned what we used how we did where we are headed
Telehealth Services At FLCMH

Diabetic Retinopathy Screening

Tele ENT

Tele Dentistry

Tele Psychiatry

Distance Learning

EMR

How we started…. How we planned…. What we used…. How we did…. where we are headed….
slide19

Telehealth Program DevelopmentFUNDING SOURCES

USDA - DLT

HRSA – Rural Network Development

FINGER LAKES COMMUNITY & MIGRANT HEALTH – HIT INFRASTRUCTURE DEVELOPMENT

NYS DOH – Office of HIT

FCC – Rural Healthcare Broadband Project

from vision to reality
From Vision to Reality
  • Workscope (Who, What, Where, When, Why, How, & How much)
  • Development Workplan
  • Deployment Workplan
  • Quality Improvement
  • Document for Replication
tele ent
Tele ENT
  • Real Time -OR- Store and Forward
slide23
Tele-ENT

What the Literature Says:cost effectivefeasablereduced travel (“greener”)reduced un-necessary transfer to tertiary centerhigh patient satisfactionimages comparable to in-person assessment

slide25
Tele- Mental Health Real Time applicationa) Consultationb) Medication Managementc) psychotherapyd) Clinical conferencinge) education
slide26
Tele- Mental Health

What the Literature Says:increased access achievedclinically effective as face to facecost effectiveDecreased time to treatmenthigh patient satisfactioneffective way to manage medication (in conjunctIon with pcp)

slide27
Tele- Mental Health

FLcmh retrospective chart reviewapril – September 2010pilot site: geneva community health center Dr Charles lilly – Deb cole LCSW6 referrals Dx: depression, PTSD, Bipolarmean time to consult: 15.6 daysmean time to treatment: 4 daysed/hospitalization: 0Mean satisfaction survey score (concurrent) Patient: 4.77/5.0telepresenter: 4.024/5.0symptoms improved:

slide29
DIABETIC RETINOPATHY SCREENING

What the Literature Says:cost effectivepreserved sightincreased access for patients in remote and rural areasdecreased time to treatmentdecreased time and distance traveled

slide30
DIABETIC RETINOPATHY SCREENING

Flcmh outcomes of pilot 2008-2009pilot site: sodus community healthdrchetscerra, od# screened = 408uninsured = 88%pathology = 23 (5%)retinopathy – 3 macular degeneration -1 glaucoma - 11 cataracts – 6 mottled macula – 1 suspicious lesion -1refractory error – 47referred for dilated exam – 13

teledentistry
TELEDENTISTRY

Clinical Applications

1) Screening

2) Urgent Care Consults

3) Specialty Care Consults

slide33
TELEDENTISTRY

What the Literature Says:reliable = no statistical difference in face to face visual exam when compared to intraoral camera digital photos improved access to preventive dental care screeningfeasible for screening, diagnosis, and treatment consultationcost effective

teledentistry remote screening pilot december 2009

TeleDentistry Remote screening PILOTDecember 2009

Holley ABCD

&

Seneca County ABCD/Headstart

33 children screened

9 out of 33 diagnosed with pathology (27%)

100% have accessed follow-up treatment

slide35
TELEDENTISTRY

Finger lakes : Eastman Pediatric dentistry case studies9 referralsseneca county (5) Ages 0-5: (7)wayne county (3) 6-12: (2)ontario county (1)mean Time to consult: 13.1 daysmean time to treatment: 9.9 dayspatient survey: 4.57telepresenter survey 4.5specialist survey: 4.28

a tale from seneca county
A TALE FROM SENECA COUNTY
  • POPULATION = 34,228
  • CHILDREN LIVING IN POVERTY = 18%

(NYS 13%)

  • 2005-2007 OUTPATIENT VISITS FOR CARIES IN 3-5 YEAR OLDS = Rate 143/10,000

(NYS Rate 87.7)

- NYSDOH County Health Incidators

2007

slide37

35 miles

55 miles

50 miles

60 miles

110 miles

FLMHCP CLINICS AND NEAREST METROPOLITAN CENTERS

A TALE FROM SENECA COUNTY ABCD

teledentistry pediatric dentist consultations seneca county abcd head start

TeleDentistry Pediatric Dentist ConsultationsSeneca County ABCD/Head Start

Agri-Business Child Development

Finger Lakes Migrant Health Care Project

University of Rochester Medical Center-Eastman Dental Program

13 April 2010

telemedicine equipment
Telemedicine Equipment
  • Sometec Intraoral Camera
  • Tandberg Portable Videoconferencing Unit
case presentation
Case Presentation

Here, Phyllis begins a consultation by providing a case presentation to Dr. Jeff Karp, DDS, at Eastman Dental, with the University of Rochester Medical Center. Information shared included medical history, diagnosis at prior screening/exam, and any social or economic barriers affecting the family’s ability to complete treatment.

case presentation41
Case Presentation

While Phyllis presents her information to Dr. Karp, we see him on the Tandberg unit, listening to the case.

intraoral examination44
Intraoral Examination

Here is an example of a tooth with severe decay. Thanks to the precision of the camera’s focus and image capture, Dr. Karp is able to use these images to determine the level of treatment a child needs, including sedation methods, (which will also determine treatment locations, i.e. OR vs. dentist’s office) preoperative medications, and behavioral considerations.

other highlights
Other Highlights

Goofing around with Dr. Jeff before the examination!

other highlights46
Other Highlights

Hugs for Miss Phyllis!

distance learning emr etc
Distance Learning, EMR, Etc.
  • FLCMH Board Training
  • Cultural Training
  • E-Clinical Works
  • Meetings
  • ETC….. ETC……
swot analysis lessons learned
SWOT Analysis & Lessons Learned

S: Vision, Passion, Positive attitude, Project Management

W: Financial limitation, technology resources, change is hard work!

learning as we go, Project Management

O: Limitless if + time, money, staff

T: doubts, stamina, fear of IT, payors, malpractice, mobility and special needs of MFW

what does the future hold
What Does The Future Hold
  • TelePulmonary Consults
  • Tele-Occ Med Consults
  • Home Based Monitoring
  • Expand Teledentistry to PCP, Headstart,
  • HCCN
slide52
RESOURCES

Dorrian, C. Ferguson, J., Ah-See, K., Bow, C., Lalla, K., VAnderpol, M., McKenzie, L., Wooton, R. (2009). Feasibility of ENT tele-endocopy as suitable method of health care delivery. Journal of Telemedicine and Telecare, 15 (3), 118-121.Duka, M. Mikalovic, B., Miladinovic, M., Jankovic, A. , Vujicic, B. (2009). Evaluation of telemedicine systems for impacted molar diagnosis. VognosactetskiPreglid, 66 (12), 985-991.Frictor, J. and Chen, H. (2009). Using teledentistry to improve access to dental care for underserved. Dental Clinics of North America, 53 (3), 537-548. Garcia-Lizana, F. and Munoz-Mayora, J. (2010). What about telepsychiatry? a systematic review. Journal of Clinical Psychiatry. 12 (2). Jones, S. and Edwards, Rt. (2010). Diabetic retinopathy screening: a systematic review of economic evidence. Diabetic medicare, 27 (30 , 249-256. Kokesh, J., Ferguson, A. PAtriocoski, C., Koller, K., Zwack, G., Provost, E., Holk, P. (2008). Digital images for post-surgical followup of tympanosomy in rural Alaska. 139 (1), 87-93.Kopyka-Kedzierawski, D. , Billings, R., McConnonchie, K. (2007). Feasibility and reliability to screen pre-school children or oral disease. Pediatric Dentistry, 29 (3), 209-213. Ng, M., Nthos, N., Rudinski, CJ, tennant, MT. (2009). Improving access to eye care in albertacanand. Journal of diabetic scientist technology, 3 (2), 289-296. Xu, CO. Smith, AC, Scuffhem, PA, Wooton, R. (2008). A cost analysis of telepediatric otolaryngology services. BMC Health Services Research 4:8.