Health Care In a Perfect Storm

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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]