1. PACMEDTek - 1998 Clinical Applications Denver Allen Lodge, M.E., CCE Chief Biomedical/Clinical Engineer Alaska Area Native Health Service Making It Work: Clinical and Technical Issues in Low-Bandwidth Telemedicine and Teleradiology

2. I need to I need text Alaska Native Health System Alaska Native Medical CenterAlaska Native Medical Center 7 Regional Hospitals7 Regional Hospitals 5 Physician-Based5 Physician-Based Health Centers Health Centers 22 Physician22 Physician Assistant Assistant Health Centers Health Centers 168 Rural Village168 Rural Village Health Stations Health Stations

3. Village Health Clinics emote Locations168 Remote Locations 450 CHA/PsStaff: 450 CHA/Ps 00 OPE/Yr300,000 OPE/Yr quipment$3M Equipment

4. Alaska Native Medical Center 150 Bed 5,000 Disch/Yr 225,000 OPE/Yr 50,000 Radiology Studies/Yr

5. Patient Transportation ed-Evacs/Yr90,000 Med-Evacs/Yr Yr> $40 M / Yr

6. Telecommunications Infrastructure Satellite Only (Low-Bandwidth) POTS Modem 9600 bps Frame Relay 56Kbps

7. ____}{ PHASE 1 PHASE 1 A LASKA T ELEMEDICINE P ROJECT NEEDS EVALU- ASSESSMENT ATION PHASE I - TELEMEDICINE

8. ____} - Full-Motion Video Teleconference - Narrow-Bandwidth VTC - Store & Forward Voice & Video - Telemetry & Teleradiology - Tele-Health Informatics - E-Mail for every Health Provider { PHASE 1 PHASE 2 PHASE 1 A LASKA T ELEMEDICINE P ROJECT NEEDS DEMONSTRATIONS... EVALU- ASSESSMENT ATION PHASE IIa - TELEMEDICINE

9. ____} - Human Factors Analyses - Staff Turnover/Retention Analyses - Provider/Customer Satisfaction - Utilization Review Analyses - Cost-Benefit/Sustainability Analyses - Profile / Cluster Analyses { PHASE 1 PHASE 2 PHASE 2 A LASKA T ELEMEDICINE P ROJECT NEEDS STUDY WHAT HAPPENS EVALUATION ASSESSMENT & PUBLISH FINDINGS PROCESS PHASE IIb - TELEMEDICINE

10. ____} - Full-Motion Video Teleconference - Narrow-Bandwidth VTC - Store & Forward Voice & Video - Telemetry & Teleradiology - Tele-Health Informatics - E-Mail for every Health Provider { PHASE 1 PHASE 2 PHASE 1 PHASE 3 A LASKA T ELEMEDICINE P ROJECT NEEDS DEMONSTRATIONS... EVALU- IMPLEMEN- ASSESSMENT ATION TATION $ PHASE III - TELEMEDICINE

11. Phase I - Needs Assessment performed by Alaska Native Health Board (ANHB) Phase I & II - Evaluation Methodology put in place (Phase I) & performed (Phase II) by University of Alaska - Anchorage (UAA) $ Funded through National Library of Medicine Contract N01-LM-6-3540 $3 Million, Over 3 Years 25 Villages PHASE I - TELEMED BASELINE RESEARCH

12. Phase I - Teleradiology Pilot Project (Dillingham) with Connection to ANMC PACS (Anchorage): Image Compression, Transfer, Storage, and Display $ Funded through Indian Health Service $450,000 Lease/Purchase Shared Maintenance Plan Compatible with other Alaska Federal Healthcare Partnership sites PHASE I - TELERAD PILOT PROJECT

13. Phase II - ANHB Needs Assessment yields NLM / UAA Evaluation Focus on Telemedicine Treatment of Ear Pathology $ Phase II also Funded by NLM Contract PHASE II - SCOPE OF TELEMED EVALUATION

14. Phase II - NLM Contract Demonstration Project Locations Anchorage Hub Demonstrations in 5 villages and 1 regional hub in 5 geographical regions: –Bristol Bay– South Central –Kotzebue– Yukon-Kuskokwim –Norton Sound PHASE II - TELEMEDICINE COUNTRY

15. PHASE II - LOW-BANDWIDTH TELEMED SITE COMPONENTS Equipment Cart Computer w/ Frame Grab SW, Store-&-Forward E-Mail type SW Video Otoscope, & Video Monitor, Other Assessories: Digital Camera, Flat-Bed Scanner, & Color Printer, Power Conditioner/UPS POTS Modem Connectivity

16. Phase II - Bi-directional Teleradiology Connectivity via between PACS and ~10 Physician-Provider Sites $ Funded through Project AKAMAI and the Alaska Federal Healthcare Partnership $1.4 Million, One-Time Appropriation Self Maintenance Plan Compatible with other AFHP sites PHASE II - BI-DIRECTIONAL TELERADIOLOGY With WAVELETTE COMPRESSION ON-THE-FLY

17. Phase II - Wide-Area PACS Bi-directional Connectivity Locations: Barrow– Ketchikan Bethel– Kodiak Dillingham– Kotzebue Fairbanks– Nome Juneau– Sitka PHASE II - TELERADIOLOGY COUNTRY

18. PHASE II - TELERAD SITE COMPONENTS X-Ray Film Digitizer Digitizer Compression Send Unit Frame Grabber Compression Send Unit DICOM Bridge Compression Send Unit Medium Resolution Dual-Monitor Reading Station Frame-Relay (56kbps) WAN Connectivity

19. Show 3- Minute Video Now Please

20. I need to I need text Referral Paradigm HUBHUB SPOKESPOKE NEEDLENEEDLE

21. Needle Spoke Hub TELEMEDICINE ( N E E D L E P E R S P E C T I V E ) Clinical & Technical Issues - TELEMEDICINE ( N E E D L E P E R S P E C T I V E )

22. PERSPECTIVE: Convinced Telemed is an Important Tool Excited Overwhelmed Want Hub, Spoke & Needle Contacts Want Call Coverage CONCERNS: Not be Taken for Granted or Left Out Rather See Resources Spent on Other Things Worried about Fewer Med-Evacs Some Acute Cases TELEMED NEEDLE: Certified Health Aide / Professional (CHA/P) at Village Health Clinic

23. PERSPECTIVE: Motivated Want Hub, Spoke, & Needle Contacts Improve Communication Diagnostic Tool Management Tool CONCERNS: Adequate Training Electronic Forms Capability Call Coverage Technical Support TELEMED NEEDLE: Mid-Level Provider (PAs or CNPs) at Sub-Regional Clinic

24. TELEMEDICINE & TELERADIOLOGY ( S P O K E P E R S P E C T I V E ) Clinical & Technical Issues - TELEMEDICINE & TELERADIOLOGY ( S P O K E P E R S P E C T I V E ) Needle Spoke Hub

25. PERSPECTIVE: 50%/50% Acceptance Want Hub Contacts to Specialists Access to Competition Training Tool Want Regional Support CONCERNS: Call-Back Nuisance Changing Referral Patterns Bypassing Present System Protocols TELEMED SPOKE: Physician Provider at Regional Hospital

26. PERSPECTIVE: Motivated Like Original Films to Stay in Department Emergency Reports-1H Report Time doesn’t Depend on Mail - 24 Hr CONCERNS: More Clerical Work Computer Phobia Loss of Data / Glitches Slow Transmission Times Technical Support TELERAD SPOKE: Rad Technologist at Regional Hospital

27. PERSPECTIVE: Interested / Skeptical Want Clinical Quality - Medium Resolution Emergency Reports-1H Interpretation - 24 Hr Permits Pulling Previous Exams CONCERNS: Easy User Interface Still Like Looking at Film Fast Send Rates - Compression Technical Support TELERAD SPOKE: Physician at Regional Hospital

28. Needle Spoke Hub TELEMEDICINE & TELERADIOLOGY ( H U B P E R S P E C T I V E ) Clinical & Technical Issues - TELEMEDICINE & TELERADIOLOGY ( H U B P E R S P E C T I V E )

29. PERSPECTIVE: Reluctance Follow-Up Tool Prefer High- Bandwidth Technology “Lower-48” Contact with Specialists CONCERNS: Call-Back Nuisance Changing Referral Patterns Bypassing Present System Protocols TELEMED HUB: Physician Specialist at Referral Hospital

30. PERSPECTIVE: Interested / Skeptical Want Diagnostic Quality - Hi-Res, Hi-Bw without Compression Losses Pre/Post Fetch Capability CONCERNS: Too Much Work Up-Time Easy User Interface Competition Bypass No Two Radiologists Reading Same Study Buy-In at All Levels TELERAD HUB: Radiologist at Referral Hospital

31. Phase III - Teleradiology Unidirectional Connectivity via Teleradiology to ~27 Mid-Level Provider Sites $ Funding ??? $2-3 Million, One-Time Appropriation Self Maintenance Plan Compatible with other AFHP sites PHASE III - TELERADIOLOGY NEEDLES

32. X-Ray Film Digitizer Digitizer Compression Send Unit POTS Modem Connection PHASE III - SITE COMPONENTS

33. I need text here Alaska Federal Healthcare Partnership PACS/Teleradiology Plan

34. Phase III - Telemedicine Implementation Plan for ~235 Sites: Alaska Federal Health Care Access Network - (AFHCAN Project ) Major portion of $ Funded by special appropriation from Congress, through the Indian Health Service $30 Million over 4 Years Self Maintenance Plan Compatible with other NLM sites PHASE III - TAKING LOW-BANDWIDTH TELEMEDICINE STATE-WIDE

35. PHASE III - AFHCAN TELEMED SITE COMPONENTS ~688 Telemed Workstations NLM-Compatible Stations Full Compliment of Scopes: »Otoscope/Ophthalmoscope »Dental Scope »Derm Scope »Culposcope ~254 Telehealth Information Kiosks Satellite WAN Connectivity

36. AFHCAN PROJECT - ORGANIZATION/IMPLEMENTATION COMMITTEE MODEL: JOINT STEERING BOARD TECHNICAL TRAINING PROJECT OFFICE INFORMATION CLINICAL LEGAL BUSINESS

37. I need text to cover up Alaska Federal Healthcare Partnership Alaska Federal Healthcare Partnership AFHCAN Project Telemedicine Sites Phase III Vision: Useful, Compatible Telemedicine Technology for Every Provider Improved Access to Quality Care for Every Patient

38. - THE END - - THE END - Credits for making this presentation possible go to the following individuals: Paul Sherry, CEO - ANHC Richard Madsager, MD - ANMC Director Russell Pittman, CIO - ANMC ITS Rich Hall - ANMC ITS Fred Pearce, PhD - UAA Rob Rauls, PO - ANHB Stuart Ferguson, PhD - ANHB Denise Statz, PA - ANHB Chuck Borg - AFHCP Susan Yeager - AFHCP Victorie Heart - CHA/P John Midthun, MD - ANMC Imaging Services Gwen Obermiller, RN - ANMC Administration Eugene Smith - Maniilaq Cheryl Booth, CHP - Noatak Ralph Schaber, RT - Dillingham