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.
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
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
11
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
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
16
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
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
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
41
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
Statewide surveillance and vaccination programs, as well as present day clinical care can be a challenge in Alaska.This map here shows to scale, the State of Alaska in comparison to the contiguous United States. The red lines indicate our referral pattern for the Alaska Tribal Health System from village clinic all the way to our central hospital in Anchorage. The green lines depict our road systems in the state.We like to say that if Anchorage was Kansas City, Missouri – we have patients in Duluth Minnesota (Far North), Savannah Georgia (Southeast Atlantic Coast) and Los Angeles, California.A large proportion of our hepatitis B patients reside in southwest Alaska, where there is no road access. Access to these communities varies by season, and includes transportation by small aircraft, snow machine and boat.
Starting in the village clinic – these are the farthest satellites in the Alaska Tribal Health System. Village communities can range in population from < 100 to more than 500Medical care in the village is conducted by Community Health Aides – these are local residents who go through a rigorous 3 month didactic in basic medical care and techniques. Many village clinics are also equipped with telemedicine capabilities, by which Health Aides can work and communicate with regional doctors, as well as doctors and specialists in Anchorage during patient examination and treatment.
Regional Health Centers are in larger population hubs, populations ranging around 1000 to 20,000 residents.These are larger hospitals with greater capabilities, such as ultrasound, CT, small clinical laboratories, and limited operation.Those from village communities must usually fly by small aircraft to be transported to a regional health centerThe Maniilaq Health Center is a good example of Arctic Construction and Design – Buildings must sit up above ground because of the frozen tundra below, which causes instability during every freeze/thaw of the seasons. The permafrost below the top layer of the tundra also prohibits construction design from driving pilings for a firm foundation into the ground.
Anchorage is where the only centralized hospital in the state is located. ANMC is home to most specialized care and surgery services for the Alaska Tribal Health System.Patients from regional clinics most often travel to ANMC by commercial airline, which operate 1 or 2 flights a day from the region to Anchorage. (Weather dependent of course!).Alaska Native Medical Center is the highest trauma unit in the State of Alaska, at a Trauma 2 level. Thus, sometimes the patient must be transported once again, to Seattle, which is approximately 1500 miles away, and transported by commercial airline.
Not sure I get the links on side of this slide
The store and forward software developed by AFHCAN is used throughout the world (pics here showing that our software is being used by the space station; by providers travelling throughout Africa, using portable kits (both pics right and lower left).
There are two kinds of telemedicine, store and forward and Video teleconferencing (VTC). Some specialites are best suited for vtc and others for s&f or both. STORE AND FORWARD and vtc telemedicine are reimbursable in Alaska and Hawaii, unlike the lower 48 where only vtc is billable.
This is where it is created (rural clinic)
Cases received in rural hub or at ANMC specialty clinics. ENT and Dermatology are the two specialties that utlized telemedicine the most.
Provider surveyed report using telemedicine because it provides the best care and increased access to care
The goal of telehealth is improved patient care.
In 2011 over 30,000 telemedicine cases were created. Primary care (blue) are cases that stay within an organization, typically a case created in a village and sent to a provider in a regional hub. Specialty cases are consultations sent to and completed by a specialist at ANMC
When the telemedicine program began, a study was completed by the Audiology program showing a significant decrease in wait time. Pre-telemedicine, 47% of patients had to wait more than 4 months to be seen.Providers still travel to rural villages for field clinics. Specialties using telemedicine can spend less time with follow up visits and have more time for sicker patients.
Estimated travel savings. Blue line shows travel savings for primary care (not having to travel from village to regional hub) and specialty care (not having to travel to Anchorage to see specialist at ANMC).
Friends set-netting (personal subsistence) at the mouth of the Kasiof river.
We started LiverConnect on a wing and a prayer. It is a live telehealth program that we started without any grant funding. Myself and our other liver clinic providers participate in University of Washington’s Hepatitis C Project Echo. However, there were special needs to address in Alaska. We saw the need to discuss broader liver disease topics – not just hepatitis C and the 10:45am start time (11:45 Pacific time) didn’t work for us in Alaska.
So our staff consists of:
Participation in LiverConnect earns the participant 1 CEU/CME for each hour session attended.
So a variety of liver disease cases have been presented.
Also, we have a broad range of topics presented on liver disease, related topics and comorbid diseases.
Here are some of our distant participants visible on screen.
We had to move to a larger conference room as the word got out among local providers.
We’re working on expanding the program now. We’ll be adding AdobeConnect as a way to access LiverConnect through the internet. Also, we hope to be able to record future LiverConnect programs for later viewing and potentially CME/CEU credit to participants watching the recordings.
Possible diagnoses included: Autoimmune hepatitis, alcohol hepatitis. Case discussed among rural provider, participants and liver clinic specialists. Decision made to bring patient in for biopsy.
Currently, we have the presentations loaded onto our website – but there is no audio with those Powerpoint presentations, but you can read them.
We feel that LiverConnect is just the tip of the iceberg of ways telemedicine can be used to help improve HIV and hepatitis C patient care.Coord care: example – transplant coordination.
If you want to start your own program, these are some of the main questions we asked ourselves…
Items to consider:Do you have IT support?If you use a program such as Adobe Connect, do you need multiple licenses?Figure out how you will handle protected health information.Advertising – How? To Whom?Feedback – Complete evaluations after each session. How do you evaluate those who are not using the service?
Alaska also has a Telehealth Technology Assessment Center which evaluates telehealth equipment and works closely with telehealth resource centers to provide answers to questions about selecting appropriate technologies for telehealth programs. Website www.telehealthtac.org
The Telehealth Technology Assessment Center or TTAC provides an unbiased source of rich information on a wide variety of telehealth technologies. The TTAC serves to raise awareness of technologies, answer questions, compile information from vendors and other sources and perform in-house evaluations on technologies. The TTAC shares the information through local, regional and national channels. The TTAC tailors its service offerings based on collaboration with the 11 regional Telehealth Resource Centers or TRCs across the United States. Services rendered vary from simple phone consultations to highly complex toolkits covering the evaluation and selection of specific technologies. Their published works, recorded webinars and other resources can be found on their website at www.TelehealthTAC.org.
AFHCAN = Alaska Federal Health Care Access Network.www.afhcan.org for more information
AFHCAN offers a variety of training and educational opportunities. AFHCAN Training Program is accredited by the American Telemedicine AssociationStarting in 2011, the AFHCAN program, in collaboration with the University of Alaska began offering online certification courses in telehealth.www.afhcan.org for more information
Thank you. Brenna and I will be happy to take questions, comments about LiverConnect and telemedicine.
