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Hawaii and Pacific Island Telehealth
Experiences
Christina Higa Co-Director, Pacific Basin Telehealth Resource Center
Social Science Research Institute University of Hawai’i
Brisbane April 3-4, 2019
Innovations in
Policy, Technology and Applications
University of Hawaii TASI Programs
“One” (Samoan) + “Ocean” (Chomorro)
“one sea/ocean” connectivity
• Pan Pacific Education and Communication Experiments by Satellite (PEACESAT) 1969-2012
• Re-Purpose – Recycle Test/Weather Satellites (NASA’s ATS-1 & 3; NOAA’s GOES 2, 3 & 7)
• ”Free” Public Service Communication• Multi-Propose – Collaboration
✓Distance Learning✓Emergency Management✓Telehealth
• Notable: Kangaroo Network – Royal Flying Doctors - Medical Chests
Our History in the Pacific Islands
Take Away from the
PEACESAT Story
Maximize - Limited Small Island Resources
Work Together – Collaborate across multi-sectors
Innovate - Value repurposed/ recycled systems & networks
“Free” connectivity spurred innovation of applications
Take a moment to think about your initiatives…
How might your service be applied to another target community (rural/urban), health discipline; or another sector completely (disaster response, education, tourism), something else?
What added value can you share with the platform you are using – whether it is technical or human resources?
UH TASI Programs• Training: Pacific International
Training Desk
• Health Informatics: Pacific Health Informatics Data Center (PHIDC)
• Telehealth: Pacific Basin Telehealth Resource Center (PBTRC)
Pacific Islands on the World Map
https://d-maps.com/m/world/centrepacifique/
Marshall Islands
American Samoa
Federated States of Micronesia
Palau
Northern Mariana IslandsGuam
• Area larger than CONUS• 480K USAPI 1.4M HI Population• PBTRC: 1-State, 3 US Territories,
3 COFA with US
Hawaii & USAPI
State of Hawaii
State of Hawai`i
• 1.4 Million People
• 8 Islands, 7 inhabited
• O`ahu – 900K
• Honolulu – Health Specialists
• Interisland Travel by Air
Telehealth in Hawai`i
• Island State – telehealth still evolving?
• Increasing adoption
• Years of “Broken Record” Policy Challenges✓Reimbursement✓Liability✓Workflow/Workload✓Licensing
State of Hawai`i Stakeholders & Policy
Actions
• 2016 Stakeholder Summit
• US/State legislators, Providers, Administrators, Researchers, Family Advocates, Payer, Vendors
• White Paper Policy Challenges
Environment
• Tipping point in our country?
• Payment Reform: service/encounter to quality performance
• Bi-Partisan Support
Telehealth Law - Act 226 (1/2017)
• Requires telehealth parity
• Malpractice coverage
• Lifts restrictions on originating site
including patient home or work;
• Definition: store and forward, remote
monitoring, live consultation & mhealth
• Does not require presence of two
providers and a patient, appropriately;
• Permits provider-patient relationship to be
established via telehealth by referral
• (Provider must have HI Medical License)
Take Away from the Hawai`i Story
Systemic Issues -- Stuck because of Policy; need to change Policy…right environment to do it.
Law Does Not = Change…requires details, change takes time
Co-design? Proposition of value: What is in it for each stakeholder? What’s in it for provider, patients, community, law makers?
Emerging Initiatives in the US Affiliated Pacific Islands
Long Standing InfrastructureChallenges and Barriers
EnvironmentTiny Population/Markets, Poor Economies of Scale, Developing & Fragile Economies
InfrastructureVast Distances, Difficult and Expensive to Serve, High Travel Costs
Non-Communicable Disease (NCD)Among highest NCD related deathsRegional State of Health EmergencyLack of Specialty Care, Costly Referrals
TelecommunicationAccess/ Affordability/ReliableLack of Enabling Telecom RegulationMonopoly Environments
Telecommunication Cost Barriers
Site Name Connection TypeProvided
Connection SpeedCost USDPer/Mo.
FSM (Chuuk) T1 Internet 1.544 Mbps $ 320
Standard ADSL Internet 1 Mbps download $ 400
256 Kbps upload
RMI (Majuro) ADSL (Residential) 256 Kbps $50
1.5 Mbps $140
ADSL (Business) 3-7 Mbps $2,100 - $4,000 FSM (Pohnpei) ADSL 1.5 Mbps $600
VDSL 8 Mbps $10,192 Palau MOH Palau Telecom (Wireless on
island, Intranet Management)3 Mbps download
~$7,000Off island via satellite (O3B) 1.5 Mbps upload
Palau MOH PNCC (Wireless on island) - Off island via satellite (O3B)
4 Mbps download -1 Mbps upload ~$5,000
American Samoa
DSL (Residential)DSL (Business)
2 Mbps10 Mbps
$130$700
CNMI ADSL Internet
9 Mbps download
$325 1 Mbps
Guam ADSL (Residential) Internet
50 Mbps download 2 Mbps upload $100
Amongst the highest
worldwide
Mbps U/D Mo. Cost
Palau 3/1 $7,500 US
Hawaii 250/250 $1,200 US
GDP (2017)
Small Is. $4,000 US
US $59,000 US
80X bandwidth for 6x cheaper
• Guam - Hub
• Majuro, Kwajalein, Ebeye (RMI) Pohnpei (FSM)
• Chuuk, Yap (to be operational) and the Palau connection installed in late 2017
Infrastructure Improvements:
Micronesian Under Sea Fiber Optic
USAPI Telehealth Champion Building
and Planning WorkshopSeptember 13 to 15, 2016 Honolulu * Hawai`i
Region IX - Office of the Assistant Secretary for Health and Regional
Directors Office worked with the Office of the Assistant Secretary for
Planning and Evaluation (ASPE)
In 2010 Pohnpei was
connected to fiber but didn’t
know what to do with
it…”our eyes were opened up
to the possibilities of
telehealth and numerous
applications.”
Telehealth in Pohnpei, FSM
Telehealth Room• Pohnpei Hospital
• Negotiated: Telecom link 10Mbps $400 USD/mo. (form $5K)
• No Budget? Local NGO funding
• Room? Re-purposed
• Opening – 3 mo. after workshop
✓Demonstration of Value
✓Attracts other local NGO funding
Pohnpei State: 36,000 Pop, FSM Capital, Connected to off island fiber
• MCH Telehealth - Teleaudiology
• Pohnpei Hospital Telehealth Room (10 Mbps – Excellent Connectivity, $400/mo)
• Hokkaido Cancer Center, Japan. Tele-pathology for cancer diagnoses & life-saving interventions. Chuuk Pap Smears reads in Pohnpei
• Shriners Hospital Consultations
• Cardiology Consultation – Dr. Mahnke(Store & Forward, Complicated Echo Studies)
• Rheumatic Heart Disease Screening and Possible Follow-Up via Telehealth
Pohnpei State Hospital Tele-Pathology
Image: Kaselehlie Press, Jan. 29, 2018
Telehealth in Pohnpei
• Rheumatic Heart Disease Screening: Handheld Ultrasounds
• Tele-Consultation: neurological referrals to Shriners Hospital for Children
• Tele-Audiology: Maternal and Child Health Care Services
• Tele-Cardiology: store and forward complicated cases
• Tele-Pathology: Hokkaido Cancer Institute. Tele-pathology for cancer diagnoses & life-saving interventions, Chuuk pap reads
Regional Collaboration in Medical Training
• Pacific Islands: Gastroenterology Australian and New Zealand Gastroenterology International Training Association (ANZGITA) Dr. Chris Hair; Fiji School of Medicine, Dr. Mei Ling Perman; PohnpeiHospital, Dr. Payne Perman
• Pacific Island TB Nurses' Network (TB Case Consultation for USAPI Nurses) CDC/Australian Respiratory Council
Medical Education
Mentoring Program
Case Based Learning
Well Received in
Pacific Islands
Take Away from the Pacific Story
Importance of Champions, even if cliché
Infrastructure / Resource Constraints
Common Telehealth issues (reimbursement,
liability, patient privacy) not yet overbearing concerns
Risk Management Assessment:
Severity of the resource constraintsDire health care needsAccess to health information, consultsImperative for best care possible
Opportunities for Regional Collaboration
Final Reflections….Challenges
* What are top challenges in your initiative?
* What do the stakeholders say? How do you hear from them?
Opportunities
* How to meet Value Propositions?
* What can you do to enhance it?
* Who can you collaborate with?
Health care providers in most rural and
isolated communities are often very
innovative, creative, and willing
Mahalo!
Thank you for your Time.