Telehealth Use for Hepatitis C and HIVTelemed Experiences from Alaska

Brenna Simons,PhDLisa Townshend, ANP

Alaska Native Tribal Health Consortium

Patient Care in Alaska:Many Challenges

From the Village Clinic….

…to the Regional Health Center…

…to the Central Hospital

Savoonga to Anchorage$1000

Nuiqsut to Anchorage$1100

Chevak to Anchorage$950

Old Harbor to Anchorage$1350

Point Hope to Anchorage$980

So, what is telehealth?

State of Alaska Health and Social Services, Division of Public Healthwww.hss.state.ak.us/dph/healthplanning/telehealth

Telehealth can be used to bridge gaps in specialty care

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Telehealth in Alaska Tribal Health System

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11 year Operational History33,000 cases/year125,482 Cases

(ATHS)

Installed Customer base includes: Alaska: 248 sites, 44

organizations59 operational systems in 20111,443 providers in 201122,763 patients in 2011

Other states and countries

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Case

s Cre

ated

Cases Created per Year

Telehealth Terminology

Live-interactiveRefers 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-forwardIn 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 ExchangeThe 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 Healthwww.hss.state.ak.us/dph/healthplanning/telehealth

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Store & Forward vs Real-Time TelehealthStore & Forward

• Asynchronous Interaction

• Documents & Images• Electronic Medical

Records• Patient Education

• Radiology• Dermatology• Pathology• Oncology• Ophthalmology• Dental

• Cardiology• ENT• GI• Pulmonary• Rheumatology

• Psychology/ Psychiatry• Neurology• Speech therapy• Physical therapy

Clinical specialties for telemedicine

• Face-to-Face Interaction

• Immediate Feedback

Remoteconsultation

Real-Time (VtC)

Ear Disease Audiometer, Tympanometer,

Video OtoscopeHeart Disease

ECG & Vital Signs MonitorRespiratory Illness

Spirometer & Vital Signs Monitor

Trauma, Skin & Wound Digital Camera

Dental Problems Dental Camera

General Scanner & Forms

Store and Forward Telemedicine

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Case originated…

…Case received.

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%

Why Do You Use Telemedicine?

Best for patient care Increased access for care

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Outcomes

18ATHS (Alaska Tribal Health System) (1/1/2001 to 12/31/2011)

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Case

s Cre

ated

Cases Created per Year (by Role)

Primary Care Specialty Care

Telehealth Impact on Extended Waiting Times (> 4 months)

Data courtesy of Phil Hofstetter

47%

8%

3%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Pre-Telemed1991-2001(n=1216)

With Telemed

2002-2004(n=276)

With Telemed

2005-2007(n=210)

Perc

ent A

ppoi

ntm

ent A

vaila

bilit

y W

ith

5 M

onth

or L

onge

r Wai

t Tim

e

19

20

$0

$1,000,000

$2,000,000

$3,000,000

$4,000,000

$5,000,000

$6,000,000

$7,000,000

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Annual Travel Savings (by Case Role)

Primary Care Specialty Care

How We Use Telehealth for Hepatitis C/HIV

Goals

Provide consultation to rural providers in Alaska

Promote education about liver disease

CEUs/CMEs

Case study format

Relaxed setting for asking questions

ANTHC Liver Disease & Hepatitis Staff

2 Physician Liver Specialists

1 Nurse Practitioner

1 Microbiologist

5 Nurses

1 Information Technologist

3 Administrative/ Support Staff

Early LiverConnect Meeting

How does LiverConnect Work?

Case Created by

Rural Provider LiverConnect Staff

NotifiedOf Case

PowerpointSlides

CreatedAboutCase

LiverConnectVideoconference

Rural ProviderPresents Case &

Liver Clinic ProvidersDiscuss Case.

plusLiver Disease or

Related TopicPresentation

LiverConnect Treatment

Recommendations Made by ANTHC

Liver Disease Providersvia AFHCAN

Copy of Relevant Notes,

Labs/Tests Scanned to

AFHCAN

Follow UpPatient Form

Completedfor Future

LiverConnect

Case Types Presented at LiverConnect

Elevated LFTsAutoimmune HepatitisHepatitis C TreatmentHepatitis B TreatmentHepatocellular CarcinomaLiver TransplantAlcohol HepatitisHepatitis C and HIV CoinfectionPatient with Liver Disease in Jail

Didactic Presentations Given at LiverConnect

Liver Disease Topics Elevated LFTs Hepatitis B Hepatitis C Autoimmune Hepatitis NAFLD Alcohol Hepatitis Statins and Liver

Disease Liver Transplantation Hepatocellular

Carcinoma

Related Topics HIV Updates Elevated LFTs and HIV Depression Rheumatologic

Manifestations of HCV Motivating Patients

with SA and Liver Disease

Adverse Childhood Experiences Study

Suicide Prevention

Distance Participants

Local Participants at LiverConnect

Using AdobeConnect for Videoconferencing

Recent LiverConnect Case Study

34 y.o. Alaska Native female

Presents with nausea/vomiting

Icterus

Afebrile

No abdominal pain

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

Case YK-8 Labs

Case YK-8 Provider Questions

What’s the differential diagnosis?What other labs/tests are needed?Does patient need liver biopsy?

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.

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: 10DEXA Scan: OsteopeniaAIH Medications: Azathioprine 75mg p.o.

daily and Methylprednisolone 7mg p.o. daily

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?

Contact Information

Past LiverConnect Presentations Viewable at ANTHC Liver Disease & Hepatitis website:

http://www.anthctoday.org/community/hep/liverconnect.html

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

• Getting Started• What do you want to

accomplish?• What do you need to do this?• What works best?• Technology options

Telehealth In Your Community

Establishing a Local Telehealth Program

Technology Requirements

Legal Requirements

Handling Protected Health Information

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Feedback Mechanism

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Creating better-informed consumers of telehealth technology.

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)

AFHCAN Training Options

• 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

University of Alaska College Courses

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