1. TELEMEDICINE AND LONGTERM CARE American Association of Homes and Services for the Aging April 7, 2003 Washington, DC TELEMEDICINE AND LONGTERM CARE American Association of Homes and Services for the Aging April 7, 2003 Washington, DC Don McBeath, Director of Telemedicine Texas Tech University Health Sciences Center

2. Telemedicine… ….the basics.

3. What is Telemedicine?... the use of electronic information and communication technologies to provide and support health care when distance separates the participants...... the use of electronic information and communication technologies to provide and support health care when distance separates the participants...

4. What is Telemedicine? Telecommunications Technology + Medicine

5. Why do telemedicine? Access Access –Provide primary healthcare that would not be available otherwise –Specialty care consultations for isolated specialists, practitioners, and other health care professionals –Eliminate expensive travel and isolation –Reduce need to move patient –CME for isolated health care providers

6. Telemedicine settings Rural Rural Schools Schools Clinics Clinics Hospitals Hospitals Prisons Prisons Nursing homes/ Assisted living Nursing homes/ Assisted living

7. Emerging applications Telepharmacy Telepharmacy Teledentistry Teledentistry Broader Home Health Broader Home Health Remote Surgery Remote Surgery

8. Telemedicine began... In 1924, with the concept of a physician seeing his patient over the radio using a television screen In 1924, with the concept of a physician seeing his patient over the radio using a television screen First wave of telemedicine programs started in the 1950s First wave of telemedicine programs started in the 1950s Now in the third wave Now in the third wave Most programs that began in the 1960s- 1980s no longer exist, due to dependence on external funding Most programs that began in the 1960s- 1980s no longer exist, due to dependence on external funding

10. Telemedicine now Doubling in number of two-way interactive video programs in 90s Doubling in number of two-way interactive video programs in 90s Teleradiology, store-and-forward, remains most common application Teleradiology, store-and-forward, remains most common application Technology is rapidly changing and costs are decreasing Technology is rapidly changing and costs are decreasing Correctional is heaviest use Correctional is heaviest use Moving into private physicians use Moving into private physicians use Expanding applications Expanding applications

12. Telemedicine at Texas Tech An early pioneer in telemedicine An early pioneer in telemedicine Started in 1989 as a pilot project to deliver health care to the rural Big Bend Region of Texas Started in 1989 as a pilot project to deliver health care to the rural Big Bend Region of Texas First consult in June of 1990 from Alpine, Texas hospital First consult in June of 1990 from Alpine, Texas hospital

13. First consult, June 1990 Aida Porras, age 10

14. Aida Porras in Presidio, TX

15. Telemedicine at Texas Tech Average 2,500 consults annually Average 2,500 consults annually Over 12,000 consults since 1991 Over 12,000 consults since 1991 Telemedicine Hall of Fame by Telehealth Magazine in August 1999 Telemedicine Hall of Fame by Telehealth Magazine in August 1999 Top Ten Telemedicine Programs in 1996 and 1997 by Telemedicine and Telehealth Network Magazine Top Ten Telemedicine Programs in 1996 and 1997 by Telemedicine and Telehealth Network Magazine Ranked in the “Top 12 List” by Telemedicine Today in 1998 Ranked in the “Top 12 List” by Telemedicine Today in 1998

16. Abilene El Paso Alpine Presidio Terlingua Hart Pampa Dalhart Amarillo Childress Wichita Falls Plainview Lubbock Ft. Stockton Odessa Lamesa Snyder Coleman Stamford Anson Sierra Blanca Fort Hancock Colorado City July 2001 Levelland De Leon Texas Tech Telemedicine Network Campus Sites Amarillo Lubbock El Paso Odessa Rural Sites Alpine Hart Fort Hancock Presidio Sierra Blanca Terlingua Correctional Sites Abilene Lamesa Amarillo Lubbock Childress Pampa Colorado City Plainview Dalhart Snyder El Paso Wichita Falls Ft. Stockton Affiliated Independent Network with Hendrick Medical Center: Abilene Anson Coleman Stamford with FQHCs: De Leon El Paso Levelland

17. Types of telemedicine consults By specialty By specialty –Psychiatry63% –Orthopedics11% –Other10% –Psychology 8% –Dermatology 4% –Primary Care 4% By type By type –Correctional90% –Non-correctional 10%

18. Consults by year and specialty Correctional199419951996199719981999200020012002 Gen. Surg.11797881212192248802 Ortho9174300251213309377268260 Internal Med.1410159222613291925 Urology0222552668756842 Dermatology07276446173827585 Other Med.10131154615015172919 Psychology0000142208287251181 Psychiatry011146179187554138313261486 Correctional Total445908386439171432249821162100 Non- correctional93835435686032180243 Total1376738926789851492253022962343

19. How it works Video conference system Video conference system Cameras each end Cameras each end TV screens/computers each end TV screens/computers each end Various medical peripherals Various medical peripherals Video connection Video connection T-1 line T-1 line Satellite Satellite Phone line (POTS) Phone line (POTS) Internet Internet

20. ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) Hub Site Remote Site T-1

23. Connectivity T-1 dedicated phone line T-1 dedicated phone line Satellite Satellite ISDN ISDN High speed DSL/Cable High speed DSL/Cable ATM ATM POTS POTS LAN/WAN LAN/WAN Internet, or IP-based Internet, or IP-based

24. Compression of bandwidth Codecs compress the information to fit the broadband connection

27. Telemedicine does not/should not alter the practice of medicine. TTU telemedicine philosophy

28. Core principles of telemedicine Is only a tool (like a stethoscope) Is only a tool (like a stethoscope) Must be physician directed Must be physician directed Must be integrated into established clinical operations and routines Must be integrated into established clinical operations and routines Physician-patient relationships must be preserved Physician-patient relationships must be preserved

29. The barriers Equipment costs Equipment costs Connectivity costs Connectivity costs Reimbursement Reimbursement

30. Getting better Declining equipment costs Declining equipment costs Shared connectivity Shared connectivity Enhanced reimbursement (still an issue for nursing homes) Enhanced reimbursement (still an issue for nursing homes)

31. Long-term care telemedicine Long-term care telemedicine

32. Correctional telemedicine as a model

33. Similar scenarios Desire to not transport patients off site Desire to not transport patients off site Limited on-site primary care Limited on-site primary care No on-site specialty care No on-site specialty care Must maintain certain level of staff on- site at all times Must maintain certain level of staff on- site at all times Have stringent rules and regulations to follow Have stringent rules and regulations to follow

34. Prison off-site transport sample NumberPercentage Remain On Unit 64857.5% Transfer Off Site 47942.5% For Year 2000, medical consults only.

35. Long-term care telemedicine— goals and benefits Enhance and increase on-site primary care Enhance and increase on-site primary care Enhance and increase on-site specialty care Enhance and increase on-site specialty care Reduce ambulance transportation for off-site care Reduce ambulance transportation for off-site care Reduce unnecessary ER visits Reduce unnecessary ER visits

36. Goals and benefits-cont. Reduce risk of injury associated with transports Reduce risk of injury associated with transports Reduce loss of revenue to nursing homes Reduce loss of revenue to nursing homes Allow better community ambulance coverage with less nursing home transports Allow better community ambulance coverage with less nursing home transports On-site medial and task training On-site medial and task training

37. Goals and benefits – cont. GED (high school equivalency) training GED (high school equivalency) training Replication of operating model Replication of operating model Student training component Student training component Expand to additional services including dental Expand to additional services including dental

38. Goals and benefits – cont. Distant social and counseling services for family and caregivers Distant social and counseling services for family and caregivers Reduced family travel time Reduced family travel time

39. Texas Tech long-term care projects - Carillon project – brief pilot - Garrison project – April 2003 - West Texas Rural Nursing Home Telemedicine Network - planned

42. Carillon findings Patient satisfaction Patient satisfaction - Comfort level and communications very high - Satisfaction with exam very high - Most would do again - Most believe no diminishing of medical quality

43. Carillon findings Patient satisfaction Patient satisfaction - Only negatives on audio/hearing

44. Carillon findings Physician satisfaction Physician satisfaction - Very high overall satisfaction - Reported no limitation on their ability to treat/diagnose - Rated most consults as same as face-to-face

45. Garrison project Geriatric Teaching Nursing Home Geriatric Teaching Nursing Home Teaching and research lab for telemedicine applications in assisted living Teaching and research lab for telemedicine applications in assisted living Expose heath care providers, students, and nursing home staff to telemedicine Expose heath care providers, students, and nursing home staff to telemedicine Serve as a resource for rural nursing homes Serve as a resource for rural nursing homes

46. West Texas Rural Nursing Home Telemedicine Network Project-planned Link three rural nursing homes with Medical Director with telemedicine Link three rural nursing homes with Medical Director with telemedicine Link with Garrison Geriatric Center Link with Garrison Geriatric Center Link to Texas Tech Link to Texas Tech No community hospital No community hospital Medical Director in another community Medical Director in another community

47. What is the future of assisted living/long-term care telemedicine?

49. Greatest potential for expanded use of telemedicine!

50. Broader applications – especially in assisted living facilities Broader applications – especially in assisted living facilities Explosion in home use Explosion in home use Driven by technology and the expanding role of the Internet Driven by technology and the expanding role of the Internet