health care in a perfect storm
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TRANSCRIPT
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Healthcare in a Perfect Storm: A Time for Telemedicine & HIT
October 3, 2011
Dale C. Alverson, MD, FAAPMedical Director, Center for Telehealth and Cybermedicine
Research, University of New Mexico
IT Medical Director, LCF Research
Albuquerque, New Mexico
Past President, American Telemedicine Association
September 14, 2012
The Role of Tele-health in the Management of RuralNeuro-Emergencies Conference
Health Care Reform/PPACA
Economic Downturn
Critical Shortage of Healthcare Providers
Emerging Enabling Information Communication Technologies
Need for more Access to Care
A Time for Telemedicine & HIT
An Aging Population/Baby Boomers
EHR Adoption/HIE
PCMH
ACOs
Meaningful Use
ICD10
Major Public Health Issues Impacting our Rural Communities and their Economic Development
Hepatitis C
Behavioral Health
Diabetes
Asthma
Cancer
Oral Health
Cardiac and
Stroke Care
Gaps in Access to Health Servicesin Rural New Mexico
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Critical Gaps in Health Expertise and Services in New Mexico
Mal-distribution of Providers Lack of Access to Health Services in Rural
Communities
Only 3/33 countiesexceed the National average of physicians per 100,000 population
64% of physicians practice in 3/33 counties.
These three counties comprise only 39% of New Mexico’s Population
NMBME 2003
Mal-distribution of Health Specialty Providers in New Mexico
The blue circles indicate 65 mile distances from the 6 major specialist centers•Albuquerque •Santa Fe •Las Cruces •Farmington •Gallup •Roswell
NMBME 20035
Telehealth and Health Information Technologies
are Part of the Solution in Closing the Gaps
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Defining Telemedicine and Telehealth
1. “Tele-” comes from the Greek root word meaning “distant or remote”/ “at a distance”.
• Tele-phone
• Tele-vision
• Tele-graph
• Tele-scope
• Tele-Etc, etc, etc
How is Telehealth used? Clinical: Consultation, Direct patient Care, Case
Reviews
Educational: Providers, Students, and Patients
Research: Community-based Participatory, Outcomes driven
Administrative: Strategic planning, Operations
Health Information Exchange
Enhanced Disaster Response
Telehealth NetworksRural/Remote Health Providers Can Access Expert Medical Opinions,
Knowledge, Education via Telehealth
Rural or Remote Location
Local HealthProvider
Patient
Specialty Medical Center
Medical Specialist
AudioHigh-Resolution Images & Video
TelehealthNetwork
ConsultationDirect Patient CareCase ReviewsEducationTrainingHealth Information ExchangeCommunity-Based Research
Student
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“Back to the Future”
Case Reviews or Consultation
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ECHO: Treatment Outcomes
Outcome ECHO UNMH P-value
N=261 N=146
Minority 68% 49% P<0.01
SVR (Cure) Genotype 1/4 50% 46% NS
SVR (Cure) Genotype 2/3 70% 71% NS
SVR=sustained viral response
NEJM : 364: 23, June 9-2011, Arora S, Thornton K, Murata G, et.al.
Direct Patient Care
Maternal Fetal Medicine-High Risk Pregnancy
“Store and Forward” Capturing an image and storing it to then be forwarded for
review by a medical specialists
Examples include teleradiology, telepathology and teledermatology, tele-ophthalmology (retinal scans)
“Telemedicine” or HIE?/Large Data Files Need Broadband
Teleradiology and Image Transfer Web‐Based Portals
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Video Phone or “VOIP” with videoFamily Visitation
School Based Health Centers
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Telehealth assistants at the school or child care center provide the link to examine the eyes, ears, throat, lungs and skin.
Videoconferencing provides the “face to face” interaction.
Getting providers to think of their desktop computer as an exam room is the trick.
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Trauma Triage
Moya M, Valdez J, Yonas H, Alverson DC. The Impact of a Telehealth Web-based Solution on and Consultation. Telemedicine and eHealth, 2010; 16:945-949
44% Transfer Avoidance
27% Management Recommendation Changes
IRA HAYES Project – PTSD/TBI
Videophone (H.324)Skype
Software IP Based (H.323) Desktop IP Based (H.323)
Small Conference Room IP Based (H.323)
Telehealth Toolkit
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Videophone (H.324)Skype
Software IP Based (H.323)
Desktop IP Based (H.323)
Small Conference Room IP Based (H.323)
Telehealth Toolkit
SaaS (SIP)
Hand Held Devices- “mHealth”
BlackBerry Treo/Palm
Smart Phones
iPhone
iPhone
Droid
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Remote Monitoring
The “Smart Band-Aid”
Geospatial Information Systems (GIS) and Public Health
Superimposing health data onto maps for enhanced visualization
Improves situational awareness and consequence management
Allows distribution of resources in a more targeted manner, better mitigation of consequences, and improved outcomes.
A transdisciplinary collaborative approach between experts in:
GIS, modeling and simulation,
public health
health providers
Center for Telehealth and Cybermedicine Research
The Center for Telehealthat UNM Health Sciences Center:
•Developing New Programs•Technical, Operational, Business, and Evaluation
Planning
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LCF Research’s Mission StatementTo improve the quality, access, and cost-effectiveness of health care provided to the US population by conducting research in healthcare delivery and public health, providing continuing professional education, and advancing the meaningful use of health information technology.
• Health Services Research and Development (HSRD)
• Health Information Exchange (HIE): NMHIC
• HIT REC: EHR Adoption, Achieving Meaningful Use
• Direct Secure Messaging (DSM)
•Task Force to Explore Expanding Access to and use of Patient Information via NMHIC (TEAPIN)
Http://www.lcfresearch.org
How the NMHIC HIE Works
Clinician Requests Access to Patient Records with Patient Consent
Clinician
Hospital
ClinicianOffice
Lab
EmergencyRoom
State Public Health Depts.
Patient
Locatesthe Patient’s
Records
Gathers &Assembles the Patient’s
Records
NMHICHIE Network
NMHICHIE Network
Nationwide Health Information Network (NwHIN)
EHR Gateway
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Cloud Based
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CernerExample Integration (Cerner)
EpicExample Integration (Epic)
Value/Benefits of HIE
Access to each patient’s health information Improved situational awareness regarding patient’s
health and use of health systems, better coordination of care
Better triage and evaluation capability: Dx/Problem list, prior procedures, Rx/Medications, Allergies, tests; lab/x-ray
Improved efficiency in making diagnosis and management plans
Decrease unnecessary duplication of testsReadmission avoidance
© LCF Research 2010 33
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ROI of HIE in ED
Humana WI: [A. Tzeel, MD, MHSA; et. al. American Health & Drug Benefits l www.AHDBonline.com July/August 2011, Vol 4, No 4]
Average savings of $29 per emergency department visit compared with the control group. Decreased utilization of imaging procedures and diagnostic tests drove this cost-savings. e.g. UNMH ED: 93,566 visits 2011 = $2.7 million potential savings!
Thus when clinicians utilize HIE in the care of patients who present to the emergency department, the costs borne by a health plan providing coverage for these patients decreased.
HIE obviates unnecessary service utilization through provision of historical medical information regarding specific patients at the point of care
© LCF Research 2010 34
The New Mexico Telehealth Alliance
Telehealth Alliance
Represents a consortium of public and private health care stakeholders: “Neutral Territory” (501c3)
Reflects the diversity of our health care delivery system in New Mexico
Enables collaboration
“Networks of Networks” Providers
Consumers
Telehealth Expertise
CommunicationNetworks
Social Networks
New Mexico Telehealth ActPassed and Signed into Law 2004
Introduced by Rep. Danice Picraux (D)Supported by Sen. Susan Wilson-Beffort (R)
HOUSE BILL 58146TH LEGISLATURE - STATE OF NEW MEXICO - SECOND SESSION 2004
http://legis.state.nm.us
Authorization Bill for Telehealth:•Covers interactive video and “Store and Forward” technologies•Any Licensed Health Professional authorized to use•Covers any Originating Site Where Patient Located, including place of residence•Authorizes/Encourages Use of and Reimbursement for Telehealth(NM Medicaid has announced policies to reimburse for telehealth services)
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UNM and Other Healthcare Entities Have Established a
Working Telehealth Network in New Mexico through Collaboration
Already over 50 NM communities and over 200 sites connected and still growing
•Sangre de Cristo CHP-SBIRT-SBHC
•DOH•DOC•UNM:
-ECHO-REACH
•CHECS Net
UNM and Other Healthcare Entities Have Established a Working Telehealth Network in New Mexico through Collaboration
Hidalgo Medical Services
Hidalgo Medical Services
IHS Taos Clinic
Health CentersOf NNM
First Choice-Edgewood
IHS Dulce Clinic
IHS Zuni Clinic
Raton PublicHealth Office
Las VegasPublic Health
Office
LCDF Chaparral
LCDF East Mesa
LCDF Las CrucesLCDF Anthony
Health CentersOf NNM
Taos PublicHealth Office
First ChoiceAlbuquerqueSouth Valley SDCCHP
Adm. Office
AlbuquerqueIndian Health Service
Area Office
NM TechNetAlbuquerque Office
SBIRT partner sites
SWTAG is a “Network of Networks”
The 4 “C’s”CooperationCoordinationCollaborationCommunication
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Telemedicine andLicensure Portability
All of these Telehealth Technologies
and their Health Applications have
the potential for interstate use and would benefit from licensure
portability
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The Elephant in the Living Room
Credentialing and Privileging
Allowing by “Proxy”
The fundamental telemedicine question:Who’s being transported to whom?
The provider to the patient or the patient to the provider? If you transport yourself physically to a provider
in another state, you rely on their licensure, credentialing and privileging in that state where the provider practices
The provider doesn’t need to be licensed, credentialed and privileged in your state of residence
Why not the same for a telemedicine transport?
Telemedicine and Need for Interstate Licensure
Information and Communication Technologies can transcend state borders
Provides a means to distribute and share limited resources among states and fill gaps in access to services and decrease health disparities
Healthcare Reform will increase the demand for primary and specialty services and telemedicine can play an important role in meeting that demand
Consumers of care will see the advantages of accessing services independent of state borders
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Telemedicine and Licensure Portability
A more uniform system can enhance the interstate CVS process and better insure effective monitoring, patient safety, and quality of care without compromising state medical board autonomy, authority, and responsibility
A Web-base system can improve efficiency and ease of use (The “VetPro” model)
Three elements are crucial for portability success:1] Uniform online applications2] Centralized credentialing3] Faster processing
Allow the option of Credentialing and Privileging “by proxy” with appropriate CVS (TJC Model)
Liability and Risk Management
• Misuse
• Failure to use
• Becoming a Standard of Care
• Standards and Guidelines
http://www.americantelemed.org
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http://www.ctel.org/
http://www.telehealthresourcecenter.org/
American Telemedicine Association (ATA) and Telemedicine
Hitting the Target: “The Triple AIMS”
ImproveAccess
Improve Health
ReduceCosts
ATA and
Telemedicine
ATA
International Telemedicine and eHealth: Transforming Systems of Care in the Global
Community
Reasons to do International TelehealthMost health issues are global!
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H1N1
H5N1
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Distributed Medical Intelligence
• Knowledge Sharing Networks/Just in Time/On Demand
• Best Practices
• Evidence based
International Union
Against TB
La Lancha Medicaen la Amazonia
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Exchange of Students and Faculty
Health Care Reform/PPACA
Economic Downturn
Critical Shortage of Healthcare Providers
Emerging Enabling Information Communication Technologies
Need for more Access to Care
A Time for Telemedicine & HIT
An Aging Population/Baby Boomers
EHR Adoption/HIE
PCMH
ACOs
Meaningful Use
ICD10
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Navigating the Perfect Storm with Telemedicine & HIT
Use a broad spectrum of information communication technologies
Effective distribution of limited resources and expertise
Increasing Access to care
Bringing care to the patient; Aging in place
Decreasing unnecessary variations in care; evidence-based best practices
Improving continuity and coordination of care;The Patient Centered Medical Home
Improving health outcomes
Avoiding unnecessary hospitalizations, duplication of tests, & decreasing errors
Reducing costs; avoiding more costly care and complications, decreasing travel
Questions?
http://hsc.unm.edu/som/[email protected]