1. AFHCAN Project Stewart Ferguson, Ph.D Associate Project Director Director of Technology AFHCAN Project Office Alaska Native Tribal Health Consortium 907-729-2260 www.afhcan.org

2. AFHCAN Sites 3. AFHCAN Partners

IHS- 194 sites - 97,000 beneficiaries

VA- 1 site - 65,000 beneficiaries

US Army, US Air Force- 9 sites - 47,000 military and dependents

USCG- 4 sites - 3,000 beneficiaries

AlaskaPHN- 26 sites

4. Remoteness by Access 5. Cost of Travel 6. Types of Sites by Staffing 7. NLM - Maniilaq Data

11 Village clinics

Begin:1/26/1999

Gather: 1/15/2001

2863 Cases

8594 Images

• 3393 Video otoscope (40%)

• 5061 Digital camera (60%)

8. Lessons Learned from NLM...

Software too difficult

• If you dont use it regularly, then you will forget how to use it

Radio Medical Traffic

• 20 cases in 30 minutes

9. Radio Medical Traffic

Daily telephone calls

90 seconds / consult

Telemedicine facilitates this process

10. What is Telemedicine? Telemedicine involves the transfer of health data over a telecommunications system. Ask-a-Doc Home Health Store & Forward RMT Radio/Phone/Fax Remote RPMS VideoConference Remote Surgery Single Provider Multiple Providers 11. Workload Distribution 12. What are your key organizational goals for telehealth applications? Please rank in order of importance to your organization:

Access to care

Patient Satisfaction

Quality of Care

Information Transfer

Costs/Economics

Continuity of Care

Other

13. 14. AFHCAN Referrals 15. 16. AFHCANet

Alaska Native Medical Center (1)

Veterans Administration Medical Center (1)

Maniilaq Health Corporation (13)

SouthEast Regional Health Consortium (12)

Kodiak Area Native Association (6)

Eastern Aleutian Tribes (8)

Norton Sound Health Corporation (15)

Public Health Nursing (?)

Yukon Kuskokwim Health Corporation (47)

Bristol Bay Area Health Corporation (30)

Dialup connectivity (up to 23)

Commissioned - EAFB (1)

17. 18. 19. VoIP - Anchorage Dial Tone

Provide 24 dial tones in Anchorage

Integrate T1 into PBX at sites:

• SEARHC, KANA, NSHC, MHC

Least cost routing

Monitor traffic and cost savings:

• NSHC spends >$2000/mo

• T1 cost ~$900/mo

• 24 dial tones ~$25/mo each

20. CLINIC NETWORK AFHCAN SYSTEM CART Otoscope ECG Scanner Touchscreen CPU UPS LAN Access Point Hub PRINTER Print Server Printer SERVER AFHCAN Cold Fusion SQL Server Web Server O/S CPU BASIC COMPUTER Monitor CPU WAN Router AFHCANet 21. AFHCANet POTS/WAN Facility C CHA #3 CHA #4 Router C Facility B CHA #1 CHA #2 Server B Facility A M.D. #1 M.D. #2 Server A HTTPS/XML

CLIENT

Operating System

• Win95/98/NT/2000

• (Unix/XWindows)

Browser

• IE v4.01/v5

Acquisition Hardware

Frame Grabber

Biometrics

SERVER

Operating System

• WinNT/2000

• (Unix/Linux)

Web Server

• IIS, Apache

Cold Fusion

Database Server

• SQL, Access

Archive hardware

22. Sustainability

Organization owns equipment

Training provided on:

• Assembly, testing, burnin

• Software installation / management

• Clinical design

• Clinical usage

23. 1) Keep it Simple.

Minimal computer skills

• Touchscreens

High turnover rates (re-training)

• Few choices per screen, color coded

Language barriers

• Very selective word choice

Disparate educational levels

• Reduce complexity to few components

24. 2) Make it Sustainable and Supportable.

Easily maintained

• Open source design (.CFM)

• State Machine

Centralize Point of update or Point of Code

• Web solution - NO custom clients

• remote upgrades

Minimize initial and recurring costs

• No ongoing licenses

25. So many organizations so many software issues!

>1000 Workstations

>100 Servers

WinNT, Win2000, Unix, Linux

IE3, IE4, IE5, Netscape, Xwindows

POTS to T1 connectivity

Different patient encounter forms

RPMS / CHCS / VISTA / Meditech

Funds disappear in 2 more years

26. Aproperly designedsystem can improve the quality of health care deliverywithout savingor sending a single byte. 27. Satellites

Add 0.6 seconds to roundtrip delay

Cause web pages to load in 5 - 40 seconds

Solutions:

• Remove need for frame sets

• Caching locally

• TCP/IP registry tweaks

• Different IP stack

• IE (http) registry tweaks

• 3rd party software (e.g. Flash Networks) - mostly proxy/spoofing techniques

• 3rd party hardware

28. 29. Effect of Proxy / SSL 30. Alaska Federal Health Data Sharing Planned Project Relationships What the AFHCAN software is not ... VISTA CHCS T2P2 ? GCPR MFI Telerad AFHCAN PACS Integrator HIS Telehealth CPRS ANMC 1/02-6/03, field start 9/03 CPRS Phase Ideploy 7/00 RPMS Alpha 3/01-7/01 Beta 7/01-12/01 Phase III 2/02 RAHALL 4/00 version4 ANMC billing 6/00-10/00 Adding lab & meds Adding 10 yr data existing planned possible Going to CHCSII NPIRS/ ORYX 31. AFHCAN Evaluation

Usage - all

Evaluation questions - all

Voice over IP- SEARHC, KANA, NSHC, MHC

PE Tube Followup- MHC

Video Conferencing - SEARHC

Ear Disease- YKHC

FAS Clinic- SCF

32. FAS Clinic (SCF)

Team Approach - based on University of Washingtons nationally recognized model

• Pediatrician

• Pediatric Psychologist

• Physical Therapist

• Speech and Language Therapist

• Social Worker

• Parent Navigator / Advocate

• Clerk

• Coordinator

33. FAS Clinic (SCF)

Purpose - Develop diagnosis and treatment plan for FAS

Method - Interviews with parent and child

Technology

• VtC (digital one way mirror)

• Nikon 990 (dysmorphology)

Future - travel team, travel equipment

34. PE Tubes 35. PE Tube Followup

National standard - 4 month followups

Reality - 8 month or longer

Expect up to 90% of followups can be accomplished with reverse telemedicine

Is an image as good as an on site visit?

• Two independent on site, in person assessments.Take images

• 6 and 12 weeks later, conduct assessments from images alone.

• Compare inter-provider variability, on site versus image assessment and treatment plans

36. Develop standards to ENHANCE the interoperability of disparatetelehealth systems and applications. IMPROVE the sustainability and usability of suchsystems in future years. Provide a mechanism for meeting current andprojected FUTURE needs for data security www.hss.state.ak.us/atac Core Principles Alaska Telehealth Advisory Council - Technical Standards Workgroup 37. ACKNOWLEDGEMENTS

Technical Expertise and Design

• Tom Bohn

• Jim Rogina

• Chris Patricoski, MD

• AFHCAN Statewide Committees

Funding Sources

• DHHS - OAT

• VA

• U.S. Army

• IHS

Legacy

• NLM / UAA