1. VA Northwest Health Network Veteran Integrated Service Network (VISN) 20
Joseph L. Ronzio, DHSc, CPHIMS, SMHIMSS
VA Northwest Health Network
VISN Telehealth Coordinator
Tracy Dekelboum, MSW
Southern Oregon Rehabilitation Center and Clinics
Facility Telehealth Coordinator

2. What is Telehealth?
The VHA Office of Telehealth Services states: Utilizing telehealth services supports “providing the right care in the right place at the right time through the effective, cost-effective and appropriate use of health information and telecommunications technologies”
Utilizing Telehealth services:
Increases access to care for services not normally available at a facility;
Increases availability of and access to care for Veterans in rural locations;
Reduces travel expenses to other VA sites for care which is replaced by telehealth services;
Reduces non-VA expenses for specialty care

3. Clinical Video Telehealth (CVT)
A Process utilizing telehealth technologies to provide care and consultation between VA sites, VA sites and the home setting, and between VA and non-VA sites. This allows the patient to be examined or interviewed at a location different from the provider, via real-time interactive video images.
The VA utilizes a national video telecommunications infrastructure to support CVT.

5. VISN 20 CVT Services Telemental Health Pacemaker / ICD
Nutrition and Dietician
Move
Traumatic Brain Injury
Rehabilitation and Amputee
Diabetes
Hepatology
Pain Clinic

6. Store and Forward (S&F)
A process in which a trained imager or health technician takes digital images or captures digital data of a patients’ condition, downloads the images or data to VistA that are interpreted by a remote consulting provider.

7. VISN 20 S&F Services
For teledermatology conditions a standard point and shoot camera is utilized.
For teleretinal imaging a digital SLR camera is connected to a lens unit which can focus on and inside the eye.
Teleradiology
Epilepsy EEG diagnostics

8. Home Telehealth (HT)
A process using Home Telehealth technologies to manage Veterans with chronic diseases at their home in order to improve clinical outcomes and access to care. This program supports and complements the care by our primary care teams.

9. VISN 20 HT Services Diabetes Congestive Heart Failure (CHF)
Cardiac Care
Hypertension
Mental Health Issues: Depression & PTSD
Obesity (Tele-MOVE)

10. VISN 20 Description of Challenges of our Network
Largest amount of land of any VA Network
Very rural locations (Alaska, Southern & Eastern Oregon)
Only two major tertiary care facilities
High non-VA care and beneficiary travel costs
Benefits of our Network
VA Electronic Health Record – CPRS
Frequent communication amongst sites
Decent collaboration and support amongst sites
Pre-existing telehealth programs
Telehealth is a natural addition to the healthcare provided

11. VISN 20’s Telehealth Network
Established a standardized VISN-wide Business Structure
Designation of Facility Telehealth Coordinators (FTHCs) to oversee each facility’s telehealth activities
Implementation and use of Telehealth Clinical Technicians (TCTs) to provide technical support, training, and clinical support
Implementation of VISN wide and facility based telehealth committees
Establishment of VISN Telehealth Technical Committee comprised of Office of Information and Technology staff, Bio Medical Engineering staff, and FTHCs
Although VISN 19 has led in the development of CVT VISN wide, VISN 20 has been very proactive in implementing all elements of telehealth and a business structure

12. VISN 20’s Telehealth Network
Establishment of standardized documents proposing and facilitating all telehealth programs
Business plan
Telehealth Service Agreement (TSA’s)
Standard Operating Procedure (SOP’s)
Establishment of standardized equipment use and purchase amongst all sites of care

13. Developing a Network Wide Telehealth Program
Rural location benefits greatly from telehealth Services
Description of demographics/idiosyncrasies of locations
Developing a Telehealth program requires a mix of aggressiveness and hand holding
Share transition of technology to make aware of actual use of technology
What is in it for them?
Workload credit
Increase in Patient Access to care
Ability to have more meaningful communication with patients
Ability to be in same room as other provider provides care

14. Developing a Facility Program: SORCC Telehealth Program
The Southern Oregon Rehabilitation Center & Clinics (SORCC):
residential facility w/approximately 450 beds
provides residential and outpatient mental health and substance use rehabilitation with primary care and limited specialty care availability
approximately 16,000 unique Veterans per year
Rural Location:
Medford, our main city is considered by VA to be urban
All other areas are rural and highly rural
Treatment Sites: One Community Based Outpatient Clinic (CBOC) and one Outreach Clinic

15. Developing a Facility Program: SORCC Telehealth Program cont’d
Due to limited clinical services, telehealth is primarily “done unto us”
Will expand SORCC services to our CBOC and Outreach Clinic in 2012

16. SORCC Programs Clinical Video Telehealth Telemental Health
Tele Pain Management
Veterans Court
Home Telehealth
Store & Forward
Teleretinal Imaging
Teledermatology
Implement in 2012
Arrhythmia
Pace Maker
Home Based TMH & PC
Expansion of Diabetes Health Clinic
Pre & Post Op Clinic
Discuss hypocrisy of Arrnythmia & Pacemaker

17. Involvement in a Network Telehealth Program
Networking opportunity and support amongst FTHCs
Frequent communication
Bi-weekly organized call
As needed communication
Education on “everything telehealth” by VISN Telehealth Coordinator and Director
Diversity in skill amongst FTHCs – the whole is greater than the sum of its parts
Ability to provide “the right care in the right place, at the right time”
Providing care as “One VA”

18. Experience - CVT FY 11 Data FY10 Data FY09 Data
5,747 patient encounters
2,296 unique patients
1,788,502 patient miles of travel saved
FY10 Data
3,358 patient encounters
2,391 unique patients
Just over 1M patient miles of travel saved
FY09 Data
2,013 patient encounters
1,690 unique patients

19. Experience – Home Based CVT
First VA to launch a successful Home Based Clinical Video Telehealth for Mental Health
Patient Centered
Saved over 20,000 miles of patient travel with just over 50 patients in 1.5 years
Higher patient satisfaction than clinic based telehealth services
Significantly lower patient now show rates
Less than .5%
Traditional mental health care is 12% to 24%
Clinic based telemental health is 8% to 18%

20. Experience – CVT Provider Empowered Telework is possible
Patients are less stressed upon arrival
Patients with a history of violence

21. Experience - S&F FY 11 Data FY10 Data FY09 Data
14,596 patient encounters
FY10 Data
9,950 patient encounters
FY09 Data
8,438 patient encounters

22. Experience - S&F S&F for providers is a multiplier
1 hour face to face encounters = 5 to 15 minute image reads
There is a need for training to be accomplished by imagers
There is a need to constantly monitor imager quality
Patient follow-up can be extremely complicated
Especially if you are imaging multiple body locations with suspected problems

23. Benefits/Satisfaction/Challenges
Increase in Patient Access to care
Ability to have more meaningful communication with patients
Ability to be in same room as other provider provides care
Workload credit – telehealth is considered a face-to-face appointment
Satisfaction
High Veteran satisfaction both in communication and in elimination of lengthy travel
Provider satisfaction in communication success and ability to be present during the Veterans’ session with non-SORCC providers, skill building
Challenges
Obtaining Clinical Champions to lead efforts
Obtaining buy-in for participation
Scheduling provider and room time
Coordination with providing sites

24. Things to Never Forget
Assure purchase of sufficient bandwidth as there never seems to be enough
Assure all equipment is compatible and standardized where possible throughout the network
Develop a systematic approach for Gaining Buy-in
Benefit to patient access
Benefit to providers
Get to play with cool shiny toys 
Importance of Clinical Champions
To lead innovation
To support followers

25. Questions