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					ATA Meeting   Dec 2, 2004
                   Overview



 Indian Health Care today

 Health Information Technology in the IHS

    “eHealth”
       The IHS Electronic Health Record
       Telehealth Care
       Interoperability

 New Directions
THE IHS MISSION
            A QUICK LOOK AT
         INDIAN HEALTH SERVICE

 More than 560 federally recognized tribes

 Indian Health Service provides a comprehensive
  health service delivery system for approximately 1.6
  million of 2.5 million American Indians and Alaska
  Natives.

 12 “Areas” of the Indian Health Service, delivering
  health care to American Indian/Alaska Native
  beneficiaries in 35 states

 Federal system - 36 hospitals, 63 health centers, 44
  health stations, 5 residential treatment centers, 34
  urban Indian health projects (direct care, CHS).

 Tribal system - 13 hospitals, 158 health centers, 28
  residential treatment centers, 76 health stations, 170
  Alaska village clinics (contract, compact).
                           INDIAN HEALTH SERVICE:
Alaska                           12 “AREAS”



     Portland
                          Billings
                                                 Bemidji

                                     Aberdeen


             Phoenix
                                                                   IHS Headquarters
California                                                           Rockville, MD
                       Navajo

                                      Oklahoma
                       Albuquerque

                Tucson                                 Nashville
       INFORMATION TECHNOLOGY:
            National Context


 “The 21st century health care system is
  using a 19th century paperwork system…
  Modern medicine ought to be using
  modern technologies in order to better
  share information, in order to reduce
  medical errors, in order to reduce costs
  to our health care system by billions of
  dollars.”
      President Bush 2004
The IHS Electronic Health Record
                 The IHS EHR



 IHS and Tribal facilities in all 12 Areas are now
  using/soon to use the IHS EHR

 20 sites to be added nationally in FY 05

 Planning underway to offer EHR to all I/T/U sites
  by end of FY 08
         IHS-VHA Collaboration



 The IHS EHR as a “hybrid” product, enhancing
  clinical functionality via a graphical user
  interface for both “legacy” RPMS and new
  RPMS/VHA modules

 Planning underway for ongoing system
  development sharing with the VHA as part of an
  interagency Memorandum of Understanding
iNTEROPERABILITY
TELEHEALTH CARE
                  iNVENTORY



 National effort to better describe telehealth-
  related activities underway at Indian health
  sites
              Telehealth Care



 All IHS Areas have some current telehealth
  clinical activity

 Some Areas are more active than others – via
  broadband telehealth networks
    Alaska, Navajo, Phoenix

 3 National Programs with Telehealth
     IHS JVN Program
     IHS/OVC Child Abuse Project
     Native American Cardiology Program

 “Mature” telehealth applications predominate
    Radiology, psychiatry, dermatology
    Ophthalmology (Retinal Screening)
    With over 20 additional clinical specialties
Alaska Federal Health Care Access
        Network (AFHCAN)

 Partnership between ANTHC, IHS, DoD, VA,
 Coast Guard
 Deployment to 240 sites across Alaska
 Unique telemedicine software and carts
    Arizona Telemedicine Program



 Large participation from Navajo and Phoenix
 Areas
 Over 214,000 telemedicine events to date
                                                                                     Navajo Area Network


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             Inventory Results:
                 Overview

 Extensive AFHCAN network in Alaska

    238 Tribal sites with telehealth capability

 231 sites IHS/Tribal sites assessed in the
 “lower 48”:

    81 (36%) reported existing or near future
     telehealth program clinical activity
       IHS Joslin Vision Network



 21 sites – in 10 Areas
    CA Area with non-JVN program
 Over 5000 studies to date (1800 in FY 2004)
   IHS/Office for Victims of Crimes
         Child Abuse Project

 17 sites – in 8 IHS Areas

 Telehealth component within a project which
 emphasizes training for medical evaluation of
 child maltreatment
              Tele-Cardiology



 Capability for Tele-EKG reading, remote echo
 readings, real-time stress echo readings
 5 Areas Active + 2 Areas with planning
           Tele-mammography



 3 Locations on the Navajo Area

 New mobile women’s health van under
 development in Aberdeen
    Goal of deployment this winter – with
    satellite connectivity for readings
               Tele-psychiatry



 Active in 7 IHS Areas, 1 Area with Plans.
 Includes connections between:

    IHS/Tribal facilities – outside
          specialists
    School clinics – outside specialists
    Facility to facility internal system
          capacity (e.g. Phoenix Indian
          Medical Center)
             Tele-dermatology



 Active in 6 Areas, 2 Areas with planning

 Waiting periods for dermatology consultation
  shortened from 4 weeks to 1-2 days
                   Tele-ENT



 Over 1200 cases per year in Alaska Federal
  Health Care Access Network (AFHCAN)
              iNVENTORY:
       Other Clinical Applications

 Existing
    Primary Care
    Perinatology
    Tele-pharmacy
    General Surgery
    Child Advocacy
    Burn and Wound Care
    Pediatric specialty services (e.g. Shriners)
    Oncology
    Nephrology
    Neurology

 Under review
    eICU
    ViRtual Centers of Excellence
      Other Telehealth Activities



 Developing broadband networks in many states
  and regions

 Many distance learning opportunities and
  offerings

 Use of telehealth technologies for:
    Administrative meetings
    Program planning
    Public health information needs
    Community health outreach
Clinical Centers of Excellence
   Community Outreach


“Chapter House” Outreach
        Community Outreach




Head
Start




               Dental Screenings
                Health promotion
                 Nutrition education
                Opportunities



 Innovative Education
     Virtual Grand Rounds
     Tumor Board
     “Pathways into Health”
     Medical technician distance degree
     Certified nurse assistant training

 Telehome health
    Eg. For care of patients with diabetes and
     congestive heart failure

 Collaborations
    With VHA
    With DoD
    ATA, HRSA (OAT), AHRQ, and others
                 Possibilities



 Interoperability Demonstration/Pilot Projects
     As part of the Developing NHII

 ViRtual Centers of Clinical Excellence for Indian
  Health Care

 Evaluations Assessing the Impact of Telehealth
  Projects on Geographic Variability in Care and
  the Developing Business Model of Telehealth
  Care

 Emerging technologies …
    E.G. Surgery

 On-line Telehealth University/Training Center
        eTelehealth UNIVERSITY



 On-line resource for:
    New program development
    Inventory awareness
    Issues related to licensure, credentialing,
     and billing
    Evolving “News” on evaluation

 Possible collaboration?
On-Line Training Resource
    ViRtual Centers of Excellence



 ENT Care

 Dermatology

 Digital mammography

 Radiology

 Cardiology

 Stroke Management

 eICU

 eED
          Why ViRtual Centers?



 Economies of scale

 Licensure advantages

 BUSINESS MODEL DEVELOPMENT

 Tele-ENT, as an example:

    Already working in Alaska
    ?Extend capacity to sites in lower 48
                          INDIAN HEALTH CARE:
Alaska                 ViRtual Centers of Excellence



     Portland
                          Billings
                                                 Bemidji

                                     Aberdeen


             Phoenix

California
                       Navajo

                                      Oklahoma
                       Albuquerque

                Tucson                                 Nashville
                          INDIAN HEALTH CARE:
Alaska                 ViRtual Centers of Excellence



     Portland
                          Billings
                                                 Bemidji

                                     Aberdeen


             Phoenix

California
                       Navajo

                                      Oklahoma
                       Albuquerque

                Tucson                                 Nashville
                A ViRtual ED?



 24, 7 real-time support for ED clinicians
    Many EDs without Board certified ED
     physicians

 How would this service affect clinical outcomes
  and inter-facility transport decision/costs?

 Eg. “MedAire”
              Robotic surgery



 Virtual Simulation training for new
  procedures, competencies, etc.
        A FOCUS ON QUALITY



 TELEHEALTH CARE AS A QUALITY INITIATIVE:

   GPRA Indicators
   Healthy People 2010 Indicators
   Regional measures of Health Status
   Disparities in Health Care
                        THE INDIAN POPULATION
                               WE SERVE

       1,600,000




       1,500,000                                                         .9m
                                                                        AI/ANs
                                                                       Unserved
       1,400,000
                                                                                   1.6m
                                                                                  AI/ANs
                                                                                  Served
       1,300,000



                                                                        2.5m AI/ANs
       1,200,000
                   1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

               IHS Service Population Growth


   Population growth rate of 1.7% per year
   63% high school graduates (77% U.S.) & 9.4% college graduates (20.3% U.S.)
   32% of AI/ANs fall below poverty standard
   Unemployment is 2.5 times the US rate
                IHS APPROPRIATIONS PER CAPITA
                 COMPARED TO OTHER FEDERAL
               HEALTH EXPENDITURE BENCHMARKS

                                                                                                      MARCH 2003
$7,000




$6,000        5,915

                                 5,214              5,065
$5,000
              1999
                                 2001                         Forecast
                                                              to 2003
                                                                         3,879               3,803
$4,000
                                                                                                               3,725
                                                    1999
$3,000                                                                                       1999                                      IHS
                                                                                                               1999
                                                                         1998
$2,000
                                                                                                                                   1,914
                                                                                 Year of                                            2002
                                                                                 Last
                                                                                 Published
$1,000                                                                                                                             Medical
                                                                                 Data
                                                                                                                                    Care
                                                                                                                                              619
                                                                                                                                              Non-
                                                                                                                                             medical
  $-
            Medicare        Medical Care for    US Per Capita     Acute Medical Care   Medical Care for   FEHB Medical Care   IHS Appropriations
         Expenditures per      Veterans        Expenditures for      for Medicaid       Federal Prison    Benchmark per IHS    & Collections Per
             Enrollee        Administration    Personal Medical        Enrollees           Inmates              User                 User
                                Users              Services
             DISPARITIES:
      Health Staff/100,000 people


         AI/AN     US        Gap

MDs       73.9    220.6    66% lower

DDs       24.0     61.8    61% lower

Nurses   229.0    849.9    73% lower

RPh       42.8     71.3    40% lower
               DISPARITIES:
                 Facilities



Age of Average Facility

IHS                   32

U.S.                  9.4
WHAT HAS TELEHEALTH
    CARE DONE?
WHAT SHOULD TELEHEALTH
       CARE DO?
Opportunites for Improvement
          CLINICAL OUTCOMES



 Improved care for diabetic patients from
  IHS Joslin Vision Network Program
FACTORS THAT AFFECT
   HEALTH STATUS


       Health
     Care (10%)


      Genetic
   Predisposition
       (20%)

   Environment
      (20%)


  Behavior (50%)
         Telehealth Health:
     A Public Health Framework?

 Health Care
    Specialty Referrals
    Special Projects, such as eICU, eED

 Genetic Predisposition
    Counseling
    Early Testing

 Environment
    Planning
    Education

 Behavior
    Telehome health
      E.G. Sacred Breath Project
GASTROENTERIC & POSTNEONATAL MORTALITY
 RATES COMPARED WITH % OF HOMES WITH
    SANITATION FACILITIES FOR AI/ANs


       25
                                                                                                 90

       20                                                                                        80
                                                         % Homes with Sanitation Facilities
                                                                                                 70




                                                                                                      % Of Homes
       15
Rate




                                                                                                 60

       10                                                                                        50
                                                            Postneonatal Mortality Rate
                                                            Per 1000 Live Births
                                                                                                 40
        5
                      Gastroenteric Mortality                                                    30
                   Rate Per 100,000 Population
                         (Age-Adjusted)
        0                                                                                        20
            1967   1970            1975           1980       1985            1990         2000
                                                 Calendar Year
                                ?TELEHOME HEALTH




       25
                                                                                      90

       20                                                                             80
                                                   % Homes with Telemedicine
                                                                                      70




                                                                                           % Of Homes
       15
Rate




                                                                                      60

       10                                                                             50
                                                     Controlled DM

                                                                                      40
        5
                    Controlled BP                                                     30

        0                                                                             20
            2004   2005             2010    2015      2020           2025      2030
                                           Calendar Year
               Telehealth Care



 Not the solution for every issue!

 But telehealth care - and new information
  technology - may be a part of many of our
  evolving solutions for old health care problems
        Business Opportunities?



 IHS will be expanding its commitment to
  telehealth and related information technologies

 IHS is committed to collaborations with other
  federal agencies, state, and private sector
  partners – for demonstration projects and
  improved health care delivery
     Thanks



 Mark Carroll MD
  (928) 214-3920
mark.carroll@ihs.gov

				
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