The IHS Telehealth Program: Innovation and ROI Mark Carroll, MD.
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Transcript of The IHS Telehealth Program: Innovation and ROI Mark Carroll, MD.
The IHS Telehealth Program:Innovation and ROI Mark Carroll, MD
Overview of IHS and Indian health care
Highlights specific to the IHS Telehealth Program
Thoughts and possibilities re: strategic collaboration with the Northwest Regional Telehealth Resource Center
Objectives for this presentation
INDIAN HEALTH SERVICEMISSION, GOAL, & FOUNDATION
The The MissionMission, in partnership with American Indian and Alaska , in partnership with American Indian and Alaska Native people, is to raise their physical, mental, social and Native people, is to raise their physical, mental, social and spiritual health to the highest level.spiritual health to the highest level.
The The GoalGoal is to ensure that comprehensive, culturally acceptable is to ensure that comprehensive, culturally acceptable personal and public health services are available and accessible personal and public health services are available and accessible to all American Indian and Alaska Native people.to all American Indian and Alaska Native people.
The The FoundationFoundation is to uphold the Federal Government’s obligation is to uphold the Federal Government’s obligation to promote healthy American Indian and Alaska Native people, to promote healthy American Indian and Alaska Native people, communities and cultures, and to honor and protect the inherent communities and cultures, and to honor and protect the inherent sovereign rights of Tribes.sovereign rights of Tribes.
Provides a comprehensive health service delivery Provides a comprehensive health service delivery system for approximately system for approximately 1.9 million of 3.3 million 1.9 million of 3.3 million American Indians and Alaska Natives. American Indians and Alaska Natives.
Serves members of Serves members of 561 federally recognized Tribes561 federally recognized Tribes in in 35 states.35 states.
FY 2007 appropriation is approximately $3.2 billion. FY 2007 appropriation is approximately $3.2 billion.
Indian Health Service total staff consists of about Indian Health Service total staff consists of about 15, 15, 850 employees850 employees, which includes approximately 2,600 , which includes approximately 2,600 nurses, 930 physicians, 390 engineers, 500 nurses, 930 physicians, 390 engineers, 500 pharmacists, 300 dentists, and 170 sanitarians pharmacists, 300 dentists, and 170 sanitarians
A Quick Look at theINDIAN HEALTH SERVICE
Partnership with Partnership with Tribal GovernmentsTribal Governments
The Indian Self-Determination Act of 1975 includes an opportunity for Tribes to assume the responsibility of providing health care for their members, without lessening any Federal treaty obligation.
Tribes now administer health care contracts and compacts with the IHS valued at over $1.5 billion. This represents approximately 54% of the IHS budget authority appropriation.
163 Service Units in 12 163 Service Units in 12 Areas Located in 35 StatesAreas Located in 35 States
Indian Health Care SystemsIndian Health Care Systems
Source: IHS Regional Differences, 2000-2001Source: IHS Regional Differences, 2000-2001
HospitalsHospitals Health Health Centers Centers
Alaska Village Clinics Alaska Village Clinics Health Health Stations Stations
IHS 33 54 N/A 38Tribal 15 229 162 116
The IHS also supports 34 Urban Clinics across the The IHS also supports 34 Urban Clinics across the nation.nation.
IHS Hospital SystemIHS Hospital System
JCAHO AccreditedJCAHO Accredited
Size varies: Size varies:
156 Beds - 6 Beds156 Beds - 6 Beds
59,000 Admissions 59,000 Admissions per year per year (2006)(2006)
9,797,000 Outpatient 9,797,000 Outpatient visits per year visits per year (2006)(2006)
Rural Primary Care System – Rural Primary Care System – with some Urban Locationswith some Urban Locations
Hospital
Ambulatory Center
60% of IHS 60% of IHS hospitals and hospitals and ambulatory ambulatory centerscenters are in are in remote areasremote areas
Community Oriented Community Oriented ProgramsPrograms
Community Community oriented primary oriented primary carecare
Public health Public health emphasisemphasis
Traveling services Traveling services in remote villagesin remote villages
Community health Community health representativesrepresentatives
Village health aidsVillage health aids
Community & Community & school health school health educationeducation
Traveling dental team visits remote Traveling dental team visits remote villages in Alaskavillages in Alaska
IHS Constructs Community Water IHS Constructs Community Water Supply & Waste Disposal FacilitiesSupply & Waste Disposal Facilities
WHAT ABOUT RESULTS?WHAT ABOUT RESULTS?
Source: IHS/OPHS/DPS, June 2005 13
Mortality Rates for Indian People Mortality Rates for Indian People Have Declined Since 1973Have Declined Since 1973
80.4
76.3
66.0
64.1
59.6
57.1
45.7
39.7
38.7
16.8
0 20 40 60 80 100
Tuberculosis
Cervical Cancer
Infant Deaths
Maternal Deaths
Accidental
Homicide
Alcohol-Related
Cerebrovascular
Pneumonia & Influenza
Suicide
Percent Decrease in Mortality Rates(Adjusted for misreporting of AI/AN race on State death certificates.)
CY 2000-2002CY 2000-2002
U.S.U.S. Ratio:Ratio: AI/ANAI/AN All RacesAll Races AI/ANAI/AN RateRate RateRate to U.S. to U.S. 2001- 20032001- 2003 20022002 All RacesAll Races
MORTALITY RATE DISPARITIES MORTALITY RATE DISPARITIES CONTINUE CONTINUE
American Indians and Alaska Natives in the IHS Service Area2001-2003
(Age-adjusted mortality rates per 100,000 population)
ALL CAUSESALL CAUSES 1042.2 845.3 1042.2 845.3 1.21.2 TuberculosisTuberculosis 1.81.8 0.3 0.3 6.06.0 AlcoholismAlcoholism 43.643.6 6.7 6.7 6.56.5 DiabetesDiabetes 75.275.2 25.425.4 3.03.0 Motor vehicle crashesMotor vehicle crashes 51.151.1 15.715.7 3.33.3 Unintentional Injuries Unintentional Injuries 93.8 93.8 36.9 36.9 2.5 2.5 HomicideHomicide 12.712.7 6.1 6.1 2.12.1 SuicideSuicide 17.117.1 10.910.9 1.61.6 Cervical cancerCervical cancer 4.44.4 2.6 2.6 1.71.7 Infant deaths Infant deaths 1/1/ 9.89.8 7.0 7.0 1.41.4 Cerebrovascular diseasesCerebrovascular diseases 54.754.7 56.256.2 1.01.0 1/ Infant deaths per 1,000 live births
NOTE: American Indian and Alaska Native (AI/AN) rates were adjusted to compensate for misreporting of AI/AN race on state death certificates. AI/AN rates are based on 2000 census with bridged-race categories developed by the Census Bureau and the National Center for Health Statistics. Jan. 2007
Suicide RatesSuicide Rates Ages 15-19, by Race and GenderAges 15-19, by Race and Gender
Rates per 100,000 peopleRates per 100,000 people Source: CDC/2000
0
5
10
15
20
25
30
35
All White Black American
Indian/
Alaska
Native
Asian
AmericanHispanic
MaleFemale
0
5
10
15
20
Year
Per
cen
t
AIAN
US
Source: IHS Program Statistics and National Diabetes Surveillance System.
1980- 20041980- 2004
Prevalence of Diagnosed Diabetes:Prevalence of Diagnosed Diabetes:AI/ANs Compared to U.S. PopulationAI/ANs Compared to U.S. Population
Per Capita Expenditures Trend:Per Capita Expenditures Trend:IHS Compared to US AverageIHS Compared to US Average
$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
$3,500
$4,000
$4,500
$5,000
$5,500
$6,000
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
IHS Per Capita Expenditure
US Per Capita Expenditure
*for personal health care services
To improve service delivery in the face of: Increasing service population/need Disparities in:
Mortality dataFundingStaffingFacilities
Telehealth as a Business Tool
Indian Health Service and Indian Health Service and Health Information TechnologyHealth Information Technology
Improve health care access, Improve health care access, quality, transparency, and quality, transparency, and valuevalue
Highlight the vital Highlight the vital perspectives and priorities of perspectives and priorities of communities, as well as communities, as well as populations populations
Involve the input of our “key Involve the input of our “key stakeholders” - the American stakeholders” - the American Indian and Alaska Native Indian and Alaska Native peoplepeople
Emphasis on Emerging Tools Emphasis on Emerging Tools that:that:
What are the opportunities for shared/collaborative service delivery? To help improve
Acess to quality careValue
What are the opportunities specific to chronic care? Specialist care Care coordination/remote monitoring
Key Questions for Telehealth
IHS Telehealth Directory - 2005
National directory work done in 2005 Foundation for
targeting collaboration opportunities with IHS Areas within NRTRC ‘catchment’
All IHS Areas had active clinical telehealth underway In over 30 clinical
disciplines
Area
Telehealth Modality
By Area
Ab
erd
ee
n
Ala
ska
Alb
uqu
erq
ue
Be
mid
ji
Bill
ing
s
Ca
lifo
rnia
Na
shvi
lle
Na
vajo
Okl
ah
om
a
Ph
oen
ix
Po
rtla
nd
Tu
cso
n
Anesthesiology ● Cardiology ● ● ● ● ● ● ●
Child Abuse (IHS/OVCProgram)
● ● ● ● ● ● ● ●
Dental ● ● ● Dermatology ● ● ● ● ● ● ● ●
Endocrinology ● ● ● ENT ● ● ● ● ● e-ED ● ● ●
GI ● Geriatrics ●
HIV ● Mental Health ● ● ● ● ● ● ● ●
Nephrology ● ● Nuerology ● ● ● ●
Nutrition ● ● ● ● OB/GYN ● ●
Oncology ● ● Ophthalmology ● ● ●
IHS/JVN Teleoph ● ● ● ● ● ● ● ● ● ● ● Orthopedics ● ● ●
Pain ● ● Pediatrics ● ● Pharmacy ● ● ● ●
Pulmonology ● ● Radiology ● ● ● ● ● ● ● ●
Rehabilitation ● ● ● Rheumatology ● ●
Surgery ● ● ● ● Urology ●
Th
eleh
ea
lth
Mo
dal
ity
Wound Care ● ● ● ●
Telehealth Category Telehealth Modality
Are
a
Sta
te
Site
Dis
tanc
e L
ea
rnin
g
Ad
min
istr
ativ
e
Te
lehe
alth
Clin
ica
l Te
leh
eal
th
Alle
rgy
An
est
hesi
olo
gy
Ca
rdio
log
y C
hild
Abu
se*
De
nta
l D
erm
ato
logy
D
M M
ana
gem
ent
En
do
crin
e
EN
T
ED
D
erm
ato
logy
G
eri
atr
ics
GI
Ho
me
He
alth
In
fect
ious
Dis
eas
e
e-I
CU
M
en
tal H
eal
th
Ne
ph
rolo
gy
Ne
uro
log
y N
utr
ition
O
b/G
YN
H
em
e/O
nc
Op
hth
alm
olo
gy
IHS
/JV
N T
ele
oph
O
rth
op
edi
cs
Pa
in M
an
agem
en
t P
eri
na
tolo
gy
Ph
arm
acy
Pri
ma
ry C
are
P
ulm
ono
log
y R
ad
iolo
gy
Re
ha
bili
tatio
n
Rh
eu
mat
olo
gy
Su
rge
ry
Wo
un
d C
are
Area
ID Benewah Medical Ctr
● ●
Fort Hall Indian Health Center
● ●
Nimiipuu Health Clinic
● ●
OR
Warm Springs Health Center
● ●
WA Coleville Indian Health Clinic
● ●
Inchelium Tribal Clinic
●
Neah Bay Indian Health Center
● ●
Sanpol Tribal Clinic
●
Wynecoop Memorial Cl
● ●
Yakama Indian Hospital
● ●
● Planned
Po
rtla
nd
●* IHS-OVC Child Abuse Project
2005
Not updated since 2005
Telehealth Category Telehealth Modality
Are
a
Sta
te
Site
Dis
tanc
e L
ea
rnin
g
Ad
min
istr
ativ
e
Te
lehe
alth
Clin
ica
l Te
leh
eal
th
Alle
rgy
An
est
hesi
olo
gy
Ca
rdio
log
y C
hild
Abu
se*
De
nta
l D
erm
ato
logy
D
M M
ana
gem
ent
En
do
crin
e
EN
T
ED
G
en
etic
s G
eri
atr
ics
GI
Ho
me
He
alth
In
fect
ious
Dis
eas
e
e-I
CU
M
en
tal H
eal
th
Ne
ph
rolo
gy
Ne
uro
log
y N
utr
ition
O
b/G
YN
H
em
e/O
nc
Op
hth
alm
olo
gy
IHS
/JV
N T
ele
oph
O
rth
op
edi
cs
Pa
in M
an
agem
en
t P
eri
na
tolo
gy
Ph
arm
acy
Pri
ma
ry C
are
P
ulm
ono
log
y R
ad
iolo
gy
Re
ha
bili
tatio
n
Rh
eu
mat
olo
gy
Su
rge
ry
Wo
un
d C
are
Area Area Office ●
MT
Browing Indian Hospital
●
●
Crow Agency Indian Hospital
● ● ● ●
Ft. Belknap Indian Health Center
● ●
Lame Deer Indian Health Center
● ●*
WY Ft. Washaskie Indian Health Center
● ●*
● Planned
Bill
ing
s
●* IHS-OVC Child Abuse Project
2005
Not updated since 2005
Collaborations are Key
Within Indian health Southwest Telehealth
Consortium Alaska Federal Health Care
Access Network (AFHCAN) Inter-Area “corporate” projects
With other federal agencies Veterans Health Administration
With universities, states, and other organizations
IHS Telehealth Program:Leveraging Investments
Build on existing successes
IHS Joslin Vision Network
Retinal screening and diagnostic tele-ophthalmology services for patients with diabetes
57 sites nationally in 15 states
Single reading center at Phoenix Indian Medical Center
Over 22,000 interpretations performed to date
IHS/JVN Teleophthalmology Program
2000 - 2007
Projecting 100 Deployments by end of FY 2009
183
10011262
1624
3027
5700
4545
3537
0
5000
10000
15000
20000
25000
2000 2001 2002 2003 2004 2005 2006 2007
Program Year
Cu
mu
lati
ve S
tud
ies
0
1000
2000
3000
4000
5000
6000
An
nu
al s
tud
ies
21,000 total studies
Going Mobile
Portable JVN Proof-of-concept to
the Artic Circle in 2006
AFHCAN Telehealth8 years operational historyR&D Telehealth System10,000 cases / yearManufacturing of Medical DevicesWhole Product Solution Design Installation Training Support Marketing
Installed Customer base includes: 248 sites, 44 organizations
• 37 Tribal organizations• US Army sites (6)• US Air Force bases (3)• State of Alaska Public Health Nursing (26)• US Coast Guard clinics (5)• US Coast Guard cutters and ice breakers (6)
IHS-AFHCAN Collaboration
National Telehealth Infrastructure in Indian Health Offer a secure
enterprise solution for store-and-forward telemedicine across Indian health
Multi-Modality “Store&Forward” T-Health
Telemedicine will improve the QUALITY OF CARE for this
patient. (n=1,681)
For this case, rate the following statement:
3%
0%
10%
41%
45%
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Product Evaluation
Server infrastructure IHS core network in place
Includes capability for outside, non-IHS consultants/specialists
Multiple Areas with AFHCAN serversNashville, Phoenix, Portland
Other Area capacity expandingSome via planned expansion of
tele-consultation support for IHS AIDS-HIV telemedicine project
AFHCAN Status Report - #1
Carts not required Lots of telemedicine possible via free
software + local PCs + peripherals (e.g. digital camera)
AFHCAN-RPMS interface 1st phase being completed
Service models developing for multiple sites from different Areas Note: Tremendous opportunity for
quality, value, and system efficiencies
AFHCAN Status Report - #2
Integrated Systems of Care
Focus on standards and information systems integration AFHCAN to be
integrated with - The IHS
Electronic Health Record
And VistA Imaging
Tele-Behavioral Health
Growing experience already within Indian health Growing need National Tele-
psychiatry consultant appointed
Possible funding increases in years ahead
Informed,Empowered Patient and
Family
Productive Interactions through effective asset based partnering over time
Prepared,ProactivePractice Team
Improved achievement of patient and community goals
DeliverySystemDesign
DecisionSupport
ClinicalInformation
Systems
Self-Management
Support
Health System
Resources and Policies
Community
Health Care Organization
Care Model
Patient Driven Coordinated
Timely and Efficient
Evidence-based and Safe
Informed,Empowered Patient and
Family
Productive Interactions through effective asset based partnering over time
Prepared,ProactivePractice Team
Improved achievement of patient and community goals
DeliverySystemDesign
DecisionSupport
ClinicalInformation
Systems
Self-Management
Support
Health System
Resources and Policies
Community
Health Care Organization
Care Model
Patient Driven Coordinated
Timely and Efficient
Evidence-based and Safe
1. Develop a multidisciplinary team that optimizes the role of each member in clinic & community
2. Optimize the Care Team: each member performs at the highest level of their licensure.
3. Focus on access, efficiencies and flow
4. Provide clinical case management services for complex patients
5. Give care that patients understand and that fits with cultural background
6. Think about alternative approaches to traditional 1:1 face to face care: telehealth, group visits, etc.
7. Integrate traditional medicine
VHA CCHT Patient Numbers
0
5000
10000
15000
20000
25000
FY 03 FY05 FY 06 FY 07
Number of Patients
As of 3/30/07 25,000 pts
HOME TELEHEALTH FORHEART FAILURE
HEARTHealth Enhancement for American Indians & Alaska Natives Through
Residential Telemedicine
‘Success with Failure’
Economics of Home Telehealth
Annualized cost per patient ~ $2,500 Includes cost of equipment and shared staff
(new) to oversee day-to-day program
Annualized savings per patient ~$30,000 Assumes prevention of roughly 1.5
hospitalizations per year for patients with heart failure as primary diagnosis
Savings in Hospitalization Costs by Effectiveness, 75 Patients Enrolled, 109 expected hospitalizations.
$-
$500,000.00
$1,000,000.00
$1,500,000.00
$2,000,000.00
$2,500,000.00
27 55 82 109
Effectiveness (Hospitalizations Prevented)
__S
avin
gs__
HospCost=$20,084
Note: Cost/Hospitalization from Dasta (2005) AHA 6th Scientific Forum on Quality ofCare and Outcomes Research in Cardiovascular Disease & Stroke
POTENTIAL SAVINGS
Home T-Health Reimbursement
System savings don’t equal individual facility budget savings Savings to 3rd party insurers vs.
individual facility CHS budget
And incentives are “malaligned” E.g. Decreased hospitalizations are not
advantageous to some referral facility operating budgets
Lapsed salaries Use T-health for unfilled vacancies
Reimbursement Relies on 3rd party payer policy and rates
Cost Avoidance Eg.For contract health budgets
Agreements/contracts Shared costs among facilities/communities
for specialist FTEs/services
T-Health Business Models
Note: Percentages may not add to 100% due to multiple outcomes per case.
About 73% of the patients seen needed something done (meds, surgery, ongoing monitoring) and 27% needed to be screened out.
Alaska ENT Outcomes (n=897)
27%
22%19% 19%
23%
5%
Unnecessary &cases were
archivedwithout sending
Referred formonitoring
Meds started Referred toregional ENT
clinic
Surgery ortesting
recommendedat ANMC
Refer to otherspecialty
ENT Tele-Consultation Center
Specialists at Alaska Native Medical Center Statewide experience
via the AFHCAN network
Extended in 2006 to patients at the Yakima Indian Health facility in eastern Washington
Further extension in 2007-08 to other Indian health facilities outside Alaska “Expert triage” model
New Service Models Possible For:
Radiology
Retinopathy screening
Mental health
Dermatology
ENT
Cardiology
Pharmacy
AIDS-HIV care
Neurology
Nutrition/Dietetics
Telehealth Service “Menu”
Real-Time Store&Forward Home
Clinical Mental Health JVN Heart Failure Care
Cardiology Cardiology Diabetes Care
Rheumatology Rheumatology
Nutrition Services Dermatology
Pain Management Radiology
AIDS/HIV Care
ENT
Educational CME/Rounds Streaming Media
Pathways into Health
Programmatic Tele-Public Health
*Draft – Phoenix Area IHS* 2006
Phoenix Area IHS: 2007 Telehealth Services Available
Clinical Service Brief Description of Service
Tele-Retinal Surveillance
Diagnosis and management of diabetic eye disease via the IHS Joslin Vision Network (JVN) program
Tele-Cardiology Consultation
Consultation to primary teams from the Native American Cardiology Program for cardiovascular conditions
Tele-NutritionCare
Real-time videoconferencing between patients, families, and a certified dietician regarding nutrition services for chronic conditions
Tele-NephrologyConsultation
Consultation to primary care teams from Phoenix Area IHS adult and child nephrologists regarding kidney disorders
Home Telehealth for Heart Failure Care
Home-based care management from the Native American Cardiology Program for patients with heart failure
Tele-Behavioral Health Videoconferencing services for addiction medicine, pain management, and mental health counseling
Tele-Rheumatology Video and AFHCAN-based consultation from IHS rheumatologist
Tele-Geriatric Consultation
Consultation to primary care teams from the IHS Geriatrics consultant regarding medical care for elders
Tele-Radiology Radiology interpretations from Phoenix Indian Medical Center
Tele-Dermatology Consultation
Consultation to primary care teams from the Arizona Telemedicine Program dermatologist regarding skin conditions
IHS-NRTRC Collaboration
Possible Areas of Strategic Partnership Regional service
menu development Regional distance
education Target a specific
clinical service for the region?
Business modeling Dialogue with state
Medicaid programs Response to specific
questions and issues
Thank You