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Document Sample
“AMEDD Telehealth Overview”
Briefing to the ATA/TATRC
Advanced Briefing for Industry
COL Ron Poropatich
TATRC Senior Clinical Advisor
2 December 2004
Telehealth References
"Innovation, Demand and Investment in Telehealth", Dept. of Commerce
Report from February 2004
http://www.technology.gov/reports/TechPolicy/Telehealth/2004Report.pdf
“Revolutionizing Health Care Through Information Technology”,
President’s Information Technology Advisory Committee, June 2004
http://www.nitrd.gov
The "Framework for Strategic Action" for "The Decade of Health
Information Technology: Delivering Consumer-centric and Information-
Rich Health Care“ by Dr. Brailler (HIT czar) and Secy. Thompson, July 21,
2004.
http://www.hhs.gov/onchit/framework/hitframework.pdf
“The Doctor is Online: Secure Messaging boosts the Use of Web
Consultations”, Wall Street Journal, September 2, 2004
Telehealth Vision
Enabling Technology
Graduate Health
Medical Care
Education Delivery
Telehealth
Operationally Research &
relevant Development
Desirable Characteristics
Applied regionally
Defined outcome metrics
Self-sustaining
Technically feasible
TNEX considerations included
U. S. Army Medical Department
Telemedicine Organization
• Telemedicine & Advanced Technology Research
Center (TATRC), Fort Detrick, MD
– Manage Advanced Medical Technology competitive research programs -
congressionally directed & OTSG sponsored
– Support Operational Telemedicine deployments
• Telehealth Program Office (TPO), Fort Detrick, MD
• Army PACS Program Management Office (APMMO), Fort Detrick, MD
• Regional Medical Commands
–Tripler Army Medical Center, Honolulu, HI
–Madigan Army Medical Center, Fort Lewis, WA
–Brooke Army Medical Center, San antonio, TX
–Walter Reed Army Medical Center, Washington, DC
–Dwight David Eisenhower Army Medical Center, Augusta, GA
–Landstuhl Regional Medical Center, Germany
U. S. Army Telemedicine Program
•Secure Web based programs (Store & Forward)
•Dermatology
•Ocular health
•Cardiology (adult & child))
•Pediatrics
•Pathology
•Radiology
•Interactive real-time consultations (Video-conferencing)
•Maternal Fetal Medicine
•Genetic Counseling
•Nutrition Care
•Tumor Board
•Psychiatry (adult & child)
•Neurology (Headache clinics)
•Neurosurgery
•Distance Learning
•Weekly CME eRounds
•Combat Medic (91W) skills training
•Medical Awareness (CDC Broadcasts etc.)
•Patient Education (Nutritional Counseling/Shoe school, etc.)
AMEDD Corporate Investment in
Telehealth
• World-wide deployed capability
– Radiology (63 DICOM servers)
– Pathology (22 systems)
– Ophthalmology (LRMC, WRAMC, TAMC)
– Dermatology
• MEDCEN expertise
– BAMC
• Dermatology – 500 consults /month
• Cardiology – 200 Echo’s/month
– TAMC
• Pediatrics – 30 consults/month
– WRAMC
• Psychiatry – 130 consults/month
• Neurosurgery – 25 consults/month
TeleHealth Priorities
for the TOE/TDA
Order of Merit Evaluation Criteria
•Tele-Radiology • Functional Proponent
Top
•Tele-Dermatology • Consultant Engaged
Priorities
• Level of Financial Investment to date
• Demonstrated Clinical Business
•Tele-Pathology Process Model
•Tele-Ocular • Business case Analyses
•Tele-Psychiatry (Adult) • Medical Commander’s Support
•Tele-Echocardiography
•Tele-Neurosurgery
•Tele-Pediatrics
(+ indicators but not well positioned at this time)
Telehealth IM/IT Strategy
CIO/ACSIM
OTSG BCA Facilitation
MEDCOM 25-1
$100 M
10+ years
Mature Technologies
Subject Matter Experts • Tele-Derm
• Tele-Mental Health
• Col Poropatich • Tele-Neurosurgery
• Clinical Consultants AMEDD • Tele-Pathology
• TPO Team Implementation • Tele-Echo
Based on BCA • Tele-Radiology
• Tele-Ocular
AMEDD C&S MRMC
DOTMLPF++ Facilitation Materiel Developer - Logistician
Capabilities Development
Training
FY 04 Year in Review
• Telehealth IPT Chartered- October 2003
• Telehealth Program Office at MRMC Established -
Nov 2003 ($450K UFR to MEDCOM)
• AMEDD/TMA Telehealth Summit-Dec 2003
• Teleconsultation Requirements submitted as part of
the FY06 POM Process ( #225 e-Health Capability)
• AKO Teleconsultation Service for the Deployed
Forces - initiated April 2004
• AKO Teledermatology Policy signed – May 2004
• AMEDD Telehealth Policy signed - June 2004
• Telehealth Deployment to OIF theater – June 2004
Telehealth
E-Health /Telemedicine is the delivery of consultation and diagnosis using
telecommunications and informatics as a remedy for difficult to serve, underserved, or
expensive to serve patient populations.
MHS Domain • Access to Care
• Focus on Our Customers/ Sound
Clinical Business Practices
BSC Goal • Protect and Sustain a Healthy and
Medically Protected Force
• Return Soldiers to Duty (IP-6)
BSC Objective(s) • Healthy Soldiers (C-1)
• Streamline Access to Care (IP-10)
• Eliminate the Hassle Factor (C-10)
Organizational Fit
VA
Organizational Fit:
Foxhole BAS MEDDAC
TMC
MEDCEN
CHCS II-T CHCS II
MHS Pop Health Solution
HealtheForces,
MAMC ICDB,
TAMC CPG,
esiCHCS, ICDB,
Immunization:
BMIST, MC4, MEDBASE,
Medbase,
CHCS II-T, e-Immune, Telehealth
MEDBASE, MEDPROS, DEERS
MEDPROS, PIC
Health
Surveillance
Longitudinal EMR
Interim Build & Migration Strategy
Ocular
Mental Health Orthopedics
Cardiology Full Operating
Dermatology
Radiology Capability
Current 04 Teleconsultation
MTF
AMEDD A fully telehealth
Telehealth Application enabled
Integrating
Interne Portal Layers organization-
Experience
t
(Interim) integrated with
WEB USER CHCS II, TOL,
EWRAS,
MEDIA, EWS
Leverage existing Teleradiology Medical Education
etc.
Infrastructure to accelerate interim solution
Leverage Interim Operating Capabilities
Future
CHCS I CHCS II etc.
Longitudinal EMR developed and fielded
FY05 FY06 FY07 FY08 FY09 FY10 FY011
Operational Telemedicine
OIF2 Medical Situation
Problem: Ad-hoc teleconsultation process using non-secure email
systems and an undefined business process between deployed providers
and medical specialists at Level 5.
Outcome: No medical control
Major Goals
Secure medical communications
Streamline medical communications
Support readiness
Further define the Requirement for Teleconsultation between Levels 2-
4 and Level 5.
3
Operational Telehealth Applications
High Bandwidth – working with Signal Corps
• Radiology
• VTC – Psychiatry & Surgical mentoring (Neurosurgery)
Low Bandwidth - AKO (email with JPEG images)
• Dermatology (derm.consult@us.army.mil)
• Ocular (eye.consult@us.army.mil)
• Burn care management (burn.consult@us.army.mil)
• Cardiology (ECG & Echocardiograms)
• Dental
• Pathology – NIPRNET based
• Medical Maintenance – equipment repair
AKO Telehealth e-mail groups
• Established
– Dermatology & Ocular
• Planned
– Burn, Trauma, Infectious Disease
– Cardiology, Nephrology, GI
– Medical Ethics
• Requires administrative support to
manage and collect data (seeking GWOT
funds)
E-Mail Consultation
Theater Provider
AKO MAIL
MEDCOM E-MAIL
P
P
P
P
P TMED
P
P STATS
P
OIF2 Telehealth “Reach-Back”
Architectures …times X
Provider and Patient Notify Manage
Monitor Track
Archive Audit
CReq
Consultation Request
CResp
Consultation Response
Broker Consultant
Levels II-IV Level V
CHCS ICDB CHCSII
E-mail …times X
E-mail
INTERNET
Not integrated with
other health systems
Tele-Dermatology
Tele-Dermatology
Need 2 Consult Brokers Many other Tele-Dermatology
Tele-Dermatology
Tele-Dermatology
Tele-Dermatology
competing systems Tele-Health Apps
(GWOT request - $240K)
For instructional purposes only
AKO TDERM SUMMARY
• 390 consults: 1 April – 2 Nov 04 (7 months)
• 22 Participating dermatologists (from all RMCs) since 1 April
• 117 Different Referring Providers
– 8 Providers have submitted 31% of all consults
– 78 providers have submitted 1-2 consults
• Origination: Iraq, Kuwait, Bosnia, Afghanistan, USS John F.
Kennedy (aircraft carrier) Egypt, Qatar, Pakistan, MFO Sinai,
Germany (SMART Teams)
– 13% of all consults have originated from Camp Arifjan, Kuwait
– Many sites cannot disclose location over un-secure email
AKO TDERM SUMMARY
• Demographics
Male: 79% /Female: 21%
Median Age: 30 years old
• Top Diagnoses - 10 Categories provide 55% of all consults
– Dermatitis(most common)
– Eczema
– Tinea
– Nevus
• Utilization by Service
– Army: 77%
– Air Force: 4%
– Marines: 3%
– Navy: 5%
– Non-combatants (children, civilians etc. referred by PCMS with Civil Affairs) 3%
– Contractors: 2%
– Detainee/EPW: 1%
– Not stated or applicable: 5%
AKO TDERM SUMMARY
Metrics
• Performance
– Average response time: 4 hrs 31 minutes (to date)
– Customer feedback 100% positive
• Consults well-thought out, relevant to end-user and
complete
– Reasons for Consultation
• Most use AKO for 2nd Opinion
• Training and support by Dermatologists giving options
to providers in constrained situations.
Mission Benefits
• Estimate 17 evacuations prevented
– Return to Duty to support the mission
– Avoids costly 3 week process to evac and return-avoids lost man days
• Inter-theater coordination
– Consult manager facilitates care between units in Iraq and MAJ Smith
who runs a Combat Dermatology Center part-time (he is the only Derm
in theater)
• Expedited definitive care
– Coordinated care through the system from theater to MEDCENS
– Facilitation of appropriate care: 2 evacs (one military and one
contractor) recommended due to the severity of the problem.
• Quality of Care
– Ensure standards of care in a theater without a Dermatology service.
Telederm Costs & Savings
• Assumption- 600 consults annually if utilization remains stable.
(Current rate = 50 consults/ month x 12 months = 600/year)
• Cost Estimates:
Dermatologists (avg. 20 mins/consult @ $100/ hour) $33
Consult Management & Admin (30 mins per consult at $40/hour) $25
Corporate Oversight/Overhead 1 hr/week $90/hour; $4,680/year $9
Platform/ Bandwidth (no additional cost) $0
Equipment (no cameras purchased as part of this effort) $0
Training ( no formal training-instructions circulated on-line) $0
TOTAL….. $67
(Annualized at current rate of utilization is $40K per year)
• Cost savings:
- 17 Medevacs avoided at a savings of $340K. Data collected via a
survey at time of consult reply. $$ based on a cost of $20K per evacuation
- Lost duty time – 3 weeks average for LRMC evaluation (357 lost duty
days)
AKO Tele-Ocular
• 11 consults in 3 months (2 from optometrists, 9 primary care)
• Response Time: 6 hrs 18 min
• Demographics
– Average Age: 23
– Active Duty: 8
– Non-combatant: 1
• Reason for Consult
– Routine care (dry eyes) to Post Trauma evals
– 1 Consult to inquire about Preventative eye wear
– Requests for Information only
• Origination
– Iraqi, Afghanistan, Kuwait and Kosovo
Ophthalmomyiasis
Tallil Air Base, Iraq
4 Nov 04
Iraq
USAF MTF
Balad
67th CSH
31st CSH
Telehealth Capabilities
Dermatology
Dental
Radiology
Pathology
Ocular
Kuwait
Telehealth Capabilities:
Camp Buehring Dermatology
(Udairi)
USA Level II
Ali Al Salem Camp Doha
USAF Level II USA Level II
Camp Arifjan
USA Level II
USN Level III
Kuwait Theater Telehealth Needs
• Problem
– Lost duty time to travel to medical specialty clinics
(Rad/Ortho) – 4 hour TAT
– Patient needs escort, driver & attendant
• Radiology – 600 patients/month require imaging from remote
sites
• Orthopedic Surgery – 20 patients/month
• Translates into 22,320 personnel on Kuwait highways/year
– Consultative vs. Diagnostic quality of image intepretation
• Cost savings/ ROI
– 22,320 personnel x 4 hours = 89,280 hours of lost
duty time
– Safety concerns - auto accident exposure
Telemedicine Initiatives (Iraq)
Medweb Business Process Flow (Level III Only)
Mosul Balad
Tikrit
Baghdad Level III
Landstuhl Germany (LRMC)
ERMC Bucca
Tallil
Telemedicine Initiatives (Kuwait)
Medweb Business Process Flow (Level II and III)
Doha
Camp Arifjan
KNB
Camp Buehring
LEGEND
Messenger Camp Ali Al Saleem
Medweb Imagery Flow
Back up Routing
Radiologist Camp
Victory
Camp
Virginia
Afghanistan
TF 325 Med
(Bagram)
Telehealth capabilities
Radiology
Dermatology
Neurosurgery
Required Steps for Telehealth
Sustainment in FY05
• Continued Executive Leadership support
• Telehealth Vision-Strategic Plan
• Governance
• Stable and Reliable Funding Source
• MRMC/C&S/OTSG Collaboration
• Software Development/CHCS II integration
• Functional Support w/ Defined Clinical Business
Process
• Business Case Analyses
• DOTMLPF+ prior to Fielding
Conclusions
• Telehealth is a valid requirement for the AMEDD
• Telehealth practice is actively providing mission
and costs benefits.
• Telehealth is now a set of individualized
capabilities but should be one entity
• Telehealth should be systemized and scaled
• Dedicated Bandwidth is the rate limiting
resource for operational telehealth – requires
GO & Signal Corps support
