Telehealth is used in Alaska to provide specialty care like hepatitis C and HIV treatment to rural areas. The Alaska Native Tribal Health Consortium runs a program called LiverConnect that uses telehealth for hepatitis C and HIV consultation. LiverConnect holds weekly videoconferences where rural providers present patient cases to ANTHC specialists. The specialists provide treatment recommendations and education. Telehealth reduces costs and travel times for specialty care. It has increased access to care and reduced wait times for appointments. LiverConnect case studies show how telehealth is used to diagnose and manage conditions like autoimmune hepatitis.

1. Telehealth Use for Hepatitis C and HIV
Telemed Experiences from Alaska
Brenna Simons,PhD
Lisa Townshend, ANP
Alaska Native Tribal Health Consortium

2. Patient Care in Alaska:
Many Challenges

3. From the Village Clinic….

4. …to the Regional Health Center…

5. …to the Central Hospital

6. Nuiqsut to Anchorage
Point Hope to Anchorage $1100
$980
Savoonga to Anchorage
$1000
Chevak to Anchorage
$950
Old Harbor to Anchorage
$1350

7. Telehealth
can be used
to bridge
gaps in
specialty
care
So, what is telehealth?
State of Alaska Health and Social Services, Division of Public Health
www.hss.state.ak.us/dph/healthplanning/telehealth

8. 8

9. Telehealth in Alaska Tribal Health System
Cases Created per Year 11 year Operational
35,000
30,000
History
25,000  33,000 cases/year
Cases Created
20,000
15,000  125,482 Cases (ATHS)
10,000
5,000
0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Installed Customer base includes:
 Alaska: 248 sites, 44 organizations
59 operational systems in 2011
1,443 providers in 2011
22,763 patients in 2011
 Other states and countries
9

10. Telehealth Terminology
 Live-interactive
Refers to telemedicine encounters where the patient, primary care
provider with the patient, and the specialist in a different location are on-
line at the same time, interacting real-time and not delayed.
 Store-and-forward
In contrast to live-interactive telemedicine encounters, this means
the health provider where the patient is at stores the data from the
encounter in a digital format, and then forwards the data to a specialist.
 Health Information Exchange
The coordination of appropriate electronic records for the health
needs of the patients and providers. Security is governed by patient and
facility permission levels.
State of Alaska Health and Social Services, Division of Public Health
www.hss.state.ak.us/dph/healthplanning/telehealth

11. Store & Forward vs Real-Time
Store & Forward Telehealth Real-Time (VtC)
• Asynchronous
Interaction • Face-to-Face
• Documents & Images Remote Interaction
consultation • Immediate
• Electronic Medical
Records Feedback
• Patient Education
• Radiology • Cardiology • Psychology/ Psychiatry
Clinical
specialties for
• Dermatology • ENT • Neurology
telemedicine • Pathology • GI • Speech therapy
• Oncology • Pulmonary • Physical therapy
• Ophthalmology • Rheumatology
• Dental
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12. Store and Forward Telemedicine
 Ear Disease
 Audiometer, Tympanometer, Vide
o Otoscope
 Heart Disease
 ECG & Vital Signs Monitor
 Respiratory Illness
 Spirometer & Vital Signs Monitor
 Trauma, Skin & Wound
 Digital Camera
 Dental Problems
 Dental Camera
 General
 Scanner & Forms
12

13. 13

14. Case originated…

15. …Case received.

16. Why Do You Use Telemedicine?
Best for patient care
Helps me communicate with a doctor
Saves my organization money
Most convenient to the patient
Improves patient satisfaction
Makes me more efficient
Gives me confidence in doing the right thing for
the patient
Increase access to care
0% 10% 20% 30% 40% 50% 60% 70%
 Best for patient care
 Increased access for care
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17. Outcomes

18. Cases Created per Year (by Role)
35,000
30,000
Cases Created
25,000
20,000
15,000
10,000
5,000
0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Primary Care Specialty Care
ATHS (Alaska Tribal Health System) (1/1/2001 to 12/31/2011) 18

19. Telehealth Impact on Extended Waiting
Times (> 4 months)
50% 47%
Percent Appointment Availability With 5
45%
40%
Month or Longer Wait Time
35%
30%
25%
20%
15%
10% 8%
5% 3%
0%
Pre-Telemed With With
1991-2001 Telemed Telemed
(n=1216) 2002-2004 2005-2007
(n=276) (n=210) Data courtesy of Phil
Hofstetter
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20. Annual Travel Savings (by Case Role)
$7,000,000
$6,000,000
$5,000,000
$4,000,000
$3,000,000
$2,000,000
$1,000,000
$0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Primary Care Specialty Care
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21. How We Use Telehealth for Hepatitis C/HIV

22. Goals
Provide consultation
to rural providers in
Alaska
Promote education
about liver disease
CEUs/CMEs
Case study format
Relaxed setting for
asking questions

23. ANTHC Liver  Early LiverConnect Meeting
Disease &
Hepatitis Staff
2 Physician Liver
Specialists
1 Nurse Practitioner
1 Microbiologist
5 Nurses
1 Information
Technologist
3 Administrative/
Support Staff

24. How does LiverConnect Work?
Case Created
by
Rural Provider LiverConnect LiverConnect
Staff Videoconference
Notified
Rural Provider LiverConnect
Copy of Of Case
Presents Case & Treatment
Relevant Recommendations
Powerpoint Liver Clinic Providers
Notes, Made by ANTHC
Slides Discuss Case.
Labs/Tests Liver Disease Providers
Scanned to Created
plus via AFHCAN
AFHCAN About
Case Liver Disease or
Related Topic
Presentation
Follow Up
Patient Form
Completed
for Future
LiverConnect

25. Case Types Presented at LiverConnect
 Elevated LFTs
 Autoimmune Hepatitis
 Hepatitis C Treatment
 Hepatitis B Treatment
 Hepatocellular Carcinoma
 Liver Transplant
 Alcohol Hepatitis
 Hepatitis C and HIV Coinfection
 Patient with Liver Disease in Jail

26. Didactic Presentations Given at LiverConnect
Liver Disease Topics Related Topics
 Elevated LFTs  HIV Updates
 Hepatitis B  Elevated LFTs and HIV
 Hepatitis C  Depression
 Autoimmune Hepatitis  Rheumatologic
 NAFLD Manifestations of HCV
 Alcohol Hepatitis  Motivating Patients with
 Statins and Liver Disease SA and Liver Disease
 Liver Transplantation  Adverse Childhood
Experiences Study
 Hepatocellular Carcinoma
 Suicide Prevention

27. Distance Participants

28. Local Participants at LiverConnect

29. Using AdobeConnect for Videoconferencing

30. Recent LiverConnect Case Study
 34 y.o. Alaska Native female
 Presents with nausea/vomiting
 Icterus
 Afebrile
 No abdominal pain

31. Case YK-8 Labs
Initial Labs 10/1/11 Initial Labs 10/1/11
ALT 1166 ANA Negative
AST 896 Actin Antibody 189
Alkaline phos 226 IgG 2320
Total bilirubin 7.43 IgM 222
Hemoglobin 12.2 Hepatitis A IgM Negative
Hematocrit 37.7 Hepatitis A Ab Total Reactive/Positive
WBCs 6.5 Hepatitis B Core IgM Negative
Platelets 347 Hepatitis B Surface Ag Negative
Prothrombin Time 12.9/Inr <1 CMV Negative
PTT 36.1 Monospot Negative

32. Case YK-8 Provider Questions
 What’s the differential diagnosis?
 What other labs/tests are needed?
 Does patient need liver biopsy?

33. Case YK-8 Diagnosis - AIH
 ANA negative, Actin antibody positive, IgG elevated
 Liver Biopsy: AIH with marked activity and early
bridging fibrosis.
 Initial Treatment:
 Methylprednisolone 32mg and
 Azathioprine 25mg.

34. Case YK-8 Follow Up Feb 2012
 Current labs:
ALT: 36, AST: 32,
WBCs: 9.5, ANC: 7.5,
Hemoglobin: 10.5, Platelet Count: 425
Vitamin D 25OH Total: 10
 DEXA Scan: Osteopenia
 AIH Medications: Azathioprine 75mg p.o. daily and
Methylprednisolone 7mg p.o. daily

35. Case YK-8 Follow Up Provider Questions
 What should I be concerned about?
 What tests should I order on her and when?
 How long should she stay on azathioprine and
methylprednisolone?

36. Contact Information
Past LiverConnect Presentations Viewable at ANTHC
Liver Disease & Hepatitis website:
http://www.anthctoday.org/community/hep/liverconnect.html

37. How Telehealth Can Be Used in HCV and HIV Care
 Training Providers, Nurses, Health Aides
 Disease Management Updates
 Treatment Updates
 Comorbid Diseases
 Case Management
 Consultation for Difficult Cases
 Interactions Among Teams for Coordinated Care
 Direct Patient Interactions
 Check-in
 Reiterate education given
 Value of seeing patient face-to-face

38. Telehealth In Your Community
• Getting Started
• What do you want to
accomplish?
• What do you need to do this?
• What works best?
• Technology options

39. Establishing a Local Telehealth Program
 Technology Requirements
 Legal Requirements
 Handling Protected Health Information
 Advertisement
 Feedback Mechanism

40. 40

41. Creating better-informed consumers of
telehealth technology.
Kirt J Beck
Follow Us TTAC Director
kjbeck@TelehealthTAC.org
Main: 907.729.4703
TelehealthTAC www.telehealthtac.org
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42. AFHCAN Training Options
 AFHCAN offers a variety of training and
educational opportunities
 Train the Trainer
 Super User 3-day
 Telehealth Technical Support
 Videoconferencing user training
 E-learning options:
 Videoconferencing (VTC)
 Webinar
 AFHCAN computer-based training (CBT)

43. University of Alaska College Courses
• AFHCAN & University of Alaska offer three
college courses in telehealth
– Course 1- Telehealth Fundamentals
– Course 2 – Beyond the Basics of Telehealth
– Course 3 – Telehealth Program Management
• Completion of Courses 1&2 -certification as
Telehealth Coordinator
• Completion of all 3 courses -certification as
Telehealth Program Manager
• More information at www.afhcan.org

44. Thank You!