Stewart Ferguson, PhD Acting CIO, Alaska Native Tribal Health Consortium and Director, Alaska Federal Health Care Access Network (AFHCAN) John Kokesh, MD Medical Director, Department of Otolaryngology, Alaska Native Medical Center (2/11/10, Workshop 3, 12.30)

1. Learning From
Alaska’s Telehealth Experience
Stewart Ferguson, PhD
John Kokesh, MD

2. 2

3. 3

4. 4

5. Stewart Ferguson Ph.D. is Acting CIO for the Alaska Native Tribal Health
Consortium and Director of the Alaska Federal Health Care Access
Network (AFHCAN). He currently serves as Vice President of the
American Telemedicine Association.
He has been involved in development for CT scanners, the forward and inverse
problems in biomagnetism, and imaging techniques for cardiac activity. He holds
M.S. and Ph.D. degrees both in Biomedical Engineering, and B.S. degrees in both
Mathematics and Electrical Engineering.
John Kokesh, MD is Medical Director of the Department of
Otolaryngology at the Alaska Native Medical Center where has has
worked for the past 17 years. His a full time clinician whose focus in
telehealth is developing clinical applications, clinical outcomes
research, education and business processes for store and forward
telemedicine.
He received his M.D. degree, residency training and head and neck oncology
fellowship training at the University of Washington. He holds clinical faculty
appointments at the University of Washington, Loyola University of Chicago and
Central Michigan University. He is a fellow of the American Board of
5
Otolaryngology.

6. Cases Created per Year  10 year Operational History
◦ 20,000 cases / year
25,000
◦ 14,000 Alaska Natives served/year
20,000
Cases Created
15,000
10,000 ◦ 900 Active providers / year
5,000  Whole Product Solution
0 ◦ Design  Manufacturing  Installation 
Training  Support  Marketing
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
(Proj)
16,000
Annual Patient Involvement  Alaska: 248 sites, 44 organizations
14,000 ◦ 37 Tribal organizations
◦ US Army sites (6) & US Air Force
12,000
# Patients
10,000
8,000
6,000 bases (3)
4,000
2,000
◦ State of Alaska Public Health
0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Nursing (26)
(Proj) ◦ Community Health Centers
 Other states and countries
6

7. When one has finished
building one’s house, one
suddenly realizes that in
the process one has
learned something one
really needed to know in
the worst way – before
one began
Nietzsche, 1886
7

8. PLEASE NOTE:
Outcomes will be
presented on Thursday in
a separate session.
8

9.  TheAFHCAN Story … from
a Program perspective.
 The AFHCAN Story … from
a Clinician’s perspective.
 Skeletonsin the Closet …
what we learned, and what
we did right and wrong.
 Where to next?

10.  Theseare our
experiences.
◦ Actual mileage may vary.
 Some of these
issues only apply to
large scale systems.
◦ E.g. Apportionment,
centralization.

11. … from a Program Perspective

12. ATA Defining Telemedicine
http://www.americantelemed.org/news/definition.html 12

13. 1990-2002
Store & Live
Forward VtC
Remote
Monitoring

14.  Asynchronous.
 Low bandwidth requirements  Can create a case
 Static data – e.g. Vital signs “on the run.”
Doctor can respond
Static Images


when available.
◦ Digital camera (megapixel)  Many consults are
◦ Scans not critical.
◦ Captured video images  It is needed as a
(ENT, Dental, Opthal., Naso.) communication
 Video Clips – esp. from video tool.
devices  Fits with present
 Temporal Data: model.
ECG, stethoscope, tympanomet  Minimal onsite
technical support is
er needed.
 Textual:
◦ Health summaries
14

15.  1st in land mass
◦ 1,420 miles (N-S)
◦ 2,400 miles (E-W)
 33,900 miles of shoreline
◦ More than all of the
contiguous states combined.
National Travel and
• 47th in road miles Safety Board (NTSB)
– 75% Alaskan communities unconnected by reported 436
a road to a hospital. commuter aircraft
– 25 of these have no airport. accidents in Alaska
– 25% Alaskans (46% of Alaskan Natives) from1990-2004 (2.8
live in communities of less than 1000 accidents a month) -
people. accounting for 36%
of all commuter
• Population density is 1.1 persons/mile2 aircraft accidents in
– 70 times smaller than the national average. the US.
15

16.  49% of all physicians in Alaska are primary care
physicians (2002 data). U.S. average is 28%
 Alaska is 48th in “doctors to residents” ratio
◦ 65% are located in Anchorage
◦ Shortages in many specialties
◦ 579 Community Health Aides in 200 villages provide nearly
½ million encounters each year.
AI/AN U.S. Gap
DISPARITIES: MD 73.9 220.6 66% Lower
Health Staff per
DD 24.0 61.8 61% Lower
100,000 people
Nurse 229.0 849.9 73% Lower
16

17.  180 Small Village
Health Centers
550 Community Health
Aides/Practitioners
125 Behavioral Health
Aides
20 Dental Health
Aides/ 12 Therapists
100 Home
health/personal care
Average Alaska village attendants
 350 Residents
17

19.  Radio ’60’s
 Telephone 70’s
 Fax 80’s
 X-ray transmission 80’s
 Computer 90’s
 2 way video 90’s
 Universal Services Fund
(USF) – broadband
connectivity - 1999

20. GOAL: Evaluate the impact of low-bandwidth
telemedicine systems on costs, professional isolation
and provider/patient satisfaction
 Funded by NLM (National Library of Medicine)
Contract #N01-LM-6-3540
◦ University of Alaska Anchorage (UAA)
 Fred Pearce, Ph.D. Principal Investigator
 4 Regional Health Corporations
◦ 26 Village clinics,
 3,000 cases 9,000 images

21.  Email-Based Software
 Basic Cart with video otoscope and camera
 Shipped in small boxes and flown to clinic
 Assembled by local high school students

23.  The solution need not be
sophisticated or complex to
be clinically effective …
 … as long as providers are
able to gain value.
23

24. 40%
35%
Provider Experience
30%
Telemedicine Cases
25%
20%
15%
10%
5%
0%
0-4 5-9 10-14 15-19 20-24 25-29 30-34
Provider Years of Experience
Clinical experience of health aides
had no impact on utilization.

25.  It’s NOT about the technology –
it’s about the value proposition.
 Experienced health aides saw
the value – e.g. it let them
convince the new doc that they
really were seeing an infected ear.
 Think … “communication tool”

27.  Non-clinical factors will often
drive usage and usage
patterns … perhaps more
than clinical factors.
 A note about evaluation – be
careful! Notice Hawthorn
effect (or top ten ways to kill
telehealth usage)

28. Usage
100%
80% will grow
Telehealth Cases
faster
Linear Predictor
than the
60%
Good Predictor
40% number
of sites
20%
involved
0%
Maniilaq (11 of 11) NSHC (5 of 14) BBAHC (5 of 28) YKHC (5 of 46)
Organization (# clinics involved)

29.  Partial participation will results in
less than partial results: We’re
either all in or it’s not worth doing.
 Full participation and
organization support is the only
approach to gain desired
utilization.
 Pilots may not tell you about
larger systemic issues and may
not be predictors of usage.

30. Cases Created per Year (by Role)
6,000
5,000
Cases Created
4,000
3,000
2,000
1,000
0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
(Proj)
Primary Care Specialty Care
30

31. Source: YKHC Policy PF_O52_PC “Telemedicine Cart Use”

32.  “I will fire anyone that does
not do telemedicine” – Janet
Shackles.
 Policies work.

33. The Alaska Native Health Board
The Alaska Native Tribal Health Consortium
The Alaska Federal Health Care Partnership
The Alaska Telehealth Advisory Council
33

34.  Veterans Affairs
 DoD (Army & Air
Force)
 DHS - (USCG)
 Indian Health Service
(IHS):
 Alaska Native Tribal
Healthcare
Consortium (ANTHC)
34

35. A formal, voluntary, Underling Philosophy
interagency relationship
 Learning Organization
between the DoD, DHS,
 Patient centered
IHS and VA working
 Health care as close to
together by the sharing
home as possible
of each other’s
 Long term
resources, talents, and
relationships
experience to improve
 Respectful of individual
patient care throughout
cultures
the state of Alaska
 Evolving process
 Inclusive not exclusive
35

36. Alaska State Population: 626,932
DoD Federal/ Tribal Population
Other
DHS
DoD/DHS 72,950
VA 63,000
IHS/Tribal 115,000
VA Total 250,950
Note: Total Federal/Tribal
Population includes both “dual”
and “triple” beneficiaries
IHS &
Tribal
*2000 Census Figures

37.  Alaska Native Tribal
Health Consortium
(ANTHC)
◦ Management structure and
support
◦ AFHCAN funds were
centralized in ANTHC
 Appropriations may be used
as multi-year funds
AFHCAN MISSION: To improve access to
health care for federal beneficiaries in Alaska
through sustainable telehealth systems

38. AFHCAN MISSION
To improve access to health care for federal
beneficiaries in Alaska through sustainable
telehealth systems
Alaska
Federal
Health
Care
Access
Network

39.  Leverage existing
RELATIONSHIPS and
collaborative groups.
 Leverage their contacts.

40. EXECUTIVE BOARD TELEHEALTH
CEO / Commanders
ANMC, VA, USCG, 3MDG, BACH, 354 MDG
Team
STEERING BOARD
AFHCP Planning Board Chairman, AFHCP Project Officer, AFHCP Business Office
Director, ANMC Data Manager, and Clinical and Tribal Representatives
AFHCAN
Partners
Clinical
Training
AFHCAN
Project
Technology
Office
Business
Informatics

41.  Project Proposal with defined
bylaws
 Autonomy of organizations
 Ownership of equipment
 Maintenance of referral
patterns

42.  … for developing
mission, intent, and funding
 … for overall design: Partner
 … for making it happen:
Dedicated, committed work unit
with
staff, equipment, offices, funds, rol
es and responsibilities.
 … for making it work: Partners
plus office
42

43. ATAC members
provide direction, ATAC
leadership and
coordination of Statewide
telehealth efforts Telehealth
throughout Alaska. Issues
ANTHC AFHCP
Funded and
Operating
Supported
AFHCAN
AFHCAN
43

44.  More steering, less rowing.
 There is a role and need to involve
partners not directly involved in the
project
 Chance to involve payers, other
systems, address issues of standards
and interoperability, look to the
future, share in successes.
 Created a buzz – and a sense of
ownership beyond the project.
44

45. Primary Care
Kasan
Primary Care
Alicia Clinic
SEARHC Juneau
Roberts
Medical Center
Medical
Center
Subregional Center
Dental
Dental Primary Care
Initial Entry
Hydaburg
Clinic Dental
Both Initial &
Secondary
Specialty
Secondary Care Clinics SEARHC Sitka
Acute Care Clinics
Secondary Eye Care
Pelican Emergency
MEH
&Tertiary Diagnostic
Outsourced Clinic Services
Care Services Mental
Health
Therapy
Harborview
Haines Medical
ANMC Center Dental
Planned
Providence Angoon Clinic
Primary Care
AK (MLP)
API
Klukwan Kake (Limited Entry)
Private Clinic
MD/Dental Tenahee Clinic
Petersburg
Clinic (MLP)
Wrangall
Skagway
The Clinical System Ketchikan

46. What are your key organizational
goals for telehealth applications?
Quality of Care
Access to Care
Patient Satisfaction
Continuity of Care
Information Transfer
Cost of Care/Saving
1 2 3 4 5 6
Low Priority Average Priority High Priority
46

47.  May not tell you what you
need to know.
 May not tell you where
telehealth can impact clinical
care.
 Might not be asking the right
questions.

50.  Ear Disease
◦ Audiometer, Tympanometer,
Video Otoscope
 Heart Disease
◦ ECG & Vital Signs Monitor
 Respiratory Illness
◦ Spirometer & Vital Signs
Monitor
 Trauma, Skin & Wound
◦ Digital Camera
 Dental Problems
◦ Dental Camera
 General
◦ Scanner & Forms 50

51.  Base Cart include:
◦ Metal Frame
◦ Isolated Power System
◦ CPU and LCD Touchscreen
◦ Expansion Ports for USB, RS232,
Video In/Out, External Display
 Currently Supported Peripherals
include:
◦ Video Otoscope
◦ Digital Camera
◦ Scanner
◦ Video Conferencing
◦ ECG
◦ Spirometer
◦ Tympanometer
◦ Audiometer
◦ Dental Camera
◦ Vital Signs Monitor
◦ Stethoscope

54. National Telehealth Technology
Assessment Center
Providing a variety of resources to the
NTTAC telehealth community
• Device assessment toolkits – five this year
• Technical support to Regional Telehealth Resource
Centers
• News and information on technologies and clinical
applications
A robust online community for sharing
and learning
• Includes full access to toolkits and forums
• Hosts and records webinars
• Helps select technologies for assessment
• Will have free membership through 2010
www.TelehealthTAC.org
Made possible through support from HRSA and IHS

55.  Do NOT underestimate the value of a
well designed SYSTEM (not just a
collection of devices).
 The devil is truly in the details. This is
where you need the detail people
involved.
 Know the conditions you are
designing for.
 Involve clinicians early and often in
equipment review, and design.
 Decide if YOU want to become a
manufacturer.

56.  Simplicity is
key for Case
Creation
 Minimize
need for
keyboard
skills
 Touchscreen
 Color coded
56

57.  Rich Web
Interface
for
Specialists
 Zero
software
footprint
57

58.  Minimal computer skills:
Touchscreens
 High turnover rates (re-
training): Few choices per
screen, color coded
 Language barriers: Very
selective word choice
 Disparate educational levels:
Reduce complexity to few
components

59.  Specialist? Ease of
acquisition less
important
 Primary Care
Provider? Ease of
acquisition more
important

60.  More than hardware – the
software design is NEVER done.
 Get a solution out quick.
 Know your users – and involve
them heavily in design decisions.
 Do NOT let your developers add
every “good” idea. Mandate
clinical governance in software
design decisions.
 Again - decide if YOU want to
become a software developer.

61. Response Rate to Evaluation Questions
2010 (Proj) (n=20,004)
2009 (n=14,542)
2008 (n=11,030)
2007 (n=11,137)  Clinical
2006 (n=8,817) Committee
2005 (n=7,771) supported 1
2004 (n=7,058) question per
2003 (n=5,058) case session
2002 (n=3,431)
2001 (n=921)
 Configurable
0% 10% 20% 30% 40% 50% 60%
Response Rate (%)
70% 80% 90% 100%
questions
Consultant Responses Initiator Responses
ATHS (Alaska Tribal Health System) (1/1/2001 to 8/31/2010) 61

62.  Build in from the start
 Involve stakeholders in
design
 Remember Hawthorn

63. Noatak Health Clinic
Maniilaq Health Center
Satellite
Satellite
Alaska Native Medical
Center (ANMC) 63

64.  Solution must support the
workflow
 Do not change workflows to
support the solution.
 Workflows change. This
requires a flexible system

65.  A massive shift in
the plan allowed
for design and
Original Plan Actual Plan testing phases.
Oct 1998
 A “multiphased”
Deploy 40% NLM Deploy approach provided
confidence for the
Oct 1999 rapid deployment
Deploy 40% Equipment of a basic solution.
Support 40% selected
Oct 2000
Deploy 20% Deployment
Support 40% Begins
Oct 2001
Support 20% 250th Cart
Server-to-Server
Oct 2002
65

66.  Allow significant time for
design and development – it
will pay dividends.
 Plan for delays and problems
– contingency plans for
clinical care, problem
resolution, design changes, …

67. Provides project oversight, coordination and
centralized management
 Planning  Informatics and data
 Contractual and needs
Legal/regulatory  Clinical Program Design
 Recruitment of providers  Ongoing SLA Monitoring
 Needs and Site  Purchasing
Assessments  Deployment / Config.
 Technology Assessment  Support and Training
 Marketing
 Evaluation
67

68. Budget Budget % Budget
Lvl Description (Installation) (Support) per Site
A1 Tertiary Care Native Medical Center $1,535,200 $191,800 5.6360%
A2 Tertiary Care Military Medical Center $1,375,520 $171,840 5.0498%
B1 Hospital - Very high workload $696,800 $87,000 2.5579%
B2 Hospital - High workload $625,120 $78,040 2.2947%
B3 Hospital - Medium high workload $590,560 $73,720 2.1679%
B4 Hospital - Low high workload $397,520 $49,590 1.4591%
B5 Hospital - workload < 35,000 $354,560 $44,220 1.3014%
C1 MD Health Center - Fairbanks $497,280 $62,060 1.8254%
C2 MD Health Center - VA $425,600 $53,100 1.5622%
C3 MD Health Center - Native Primary Care Ctr $313,360 $39,070 1.1501%
C4 MD Health Center - workload 20,000-50,000 $262,800 $32,750 0.9645%
C5 MD Health Center - workload 10,000-20,000 $145,840 $18,130 0.5351%
C6 MD Health Center - workload < 10,000 $103,360 $12,820 0.3791%
D1 PA Health Center workload > 4000 $107,280 $13,310 0.3935%
D2 PA Health Center workload < 4000 $93,120 $11,540 0.3416%
E1 CHA Health Center workload > 4000 $100,240 $12,430 0.3677%
E2 CHA Health Center workload < 4000 $82,580 $10,260 0.3030%
F1 PHN Health Center workload > 4000 $79,600 $9,850 0.2919%
F2 PHN Health Center workload < 4000 $46,720 $5,740 0.1712% 68

69. Project Plan $30,685,640
5 Year Actuals (FY99-FY03)* $27,456,279
* Five Year Actuals are $28,332,505 including ATAC
Project Plan Expenditures (FY99-FY03)
Equipment (Phase 1)
Site Funds and Equipment (Phase 2)
Software Development
Project Design and Management
Deployment
Unfunded Requirements (e.g. ATAC)
0% 5% 10% 15% 20% 25% 30% 35%
Percent of Budget or Actuals
69

70.  Agree early on where the
funds sit (central … or not)
 Agree on apportionment
process
 Portion for
cash, equipment, support, …
 Portion to remain centralized

71. … from a Clinician’s Perspective

72.  Find and develop interest
 Establish acceptance
 Promote usage
 Build programs
 Integrate telehealth into the
standard way you deliver care

73. One question: Do we have a problem we
need to solve?

74. ENT Clinic Demand, Supply and Activity
(Jan 2002 - May 2003)
60
50
Patient Appointments
40
Avg Demand
30
Avg Supply
Avg Activity
20
10
0
Monday Tuesday Wednesday Thursday Friday
74

75.  If there is no perception of a
problem, look elsewhere
 If they don’t think it is broken,
you can’t fix it

76. Put the technology in their hands
Make sure it works
Let them play
Support, support, support
Go for the easy win
Talk about it

79. How satisfied were you with the use Willing to have a telemedicine
of the telemedicine technology? exam for follow-up?
25
30
20
15 20
10 10
5 0
0
No Yes
Poor Fair GoodVery
Good
Overall Satisfaction
How well did the telemedicine technology With This Visit
help you understand your problem? 25
30 20
15
20
10
10
5
0 0
PoorFair ood
G Very Poor Fair Good Very
Good Good 79

80. “I was able to see the
problem - then the
repaired normal condition
… and discussed my
problem - very
informative!”
“I liked to see with
my own eyes the
inside of my ear!”

81.  Let your customers (patients)
create your buzz.

82.  For clinicians, you have to prove it works
 There must be a value proposition
• Better?
• More efficient?
• You can do what you otherwise can’t do
• More profitable?

83.  254 sets of tubes
placed at ANMC in
2000
 1,000 follow up
appointments needed
in 12 month period
 Many of these
patients from remote
areas
83

84.  To determine if video
otoscope still images
(640 x 480 pixel resolution) of
the tympanic
membrane following
surgical placement of
tympanostomy tubes
are comparable to an
in-person microscopic
examination.

85. % CONCORDANCE ON PHYSICAL EXAM
100% 99% 99% 99%
97% 96%
95% 94%
90% 90%
InterProvider (Exam0)
85%
80% IntraProvider using all images
(Exam0 vs Review1,2)
75%
70% IntraProvider using "good" images
65% (Exam0 vs Review1,2)
% Concordance
60%
55% High level of agreement  Correlation between in person
50%
45% exam and telemedicine exam
40%
good to excellent
35%
30%  Telemedicine can be used to do
25%
20%
routine ear tube follow up
15%  Make available several hundred
10%
5%
appointments per year
0%
Tube In Tube Drainage Perforation Granulation Middle ear Retracted
Patent fluid
Physical Exam Descriptors
Kokesh J, Ferguson AS, Patricoski C, Koller K, Zwack G, Provost E, Holck P. “Digital images for postsurgical follow-up of tympanostomy
tubes in remote Alaska”. Otolaryngology-Head and Neck Surgery, 139:87-93, 2008.
Patricoski C, Kokesh J, Ferguson AS, Koller K, Zwack G, Provost E, Holck P. “A Comparison of In-Person Examination and Video Otoscope
Imaging for Tympanostomy Tube Follow-Up”. Telemedicine Journal and e-Health, 9(4):331-344, 2003.

86.  “Waiting time for a field clinic
appointment has gone from
4-5 months a year ago to 1-
2 months now. I've probably
got 100 stories of patients or
parents who were pleased
with the quicker, easier
access to ENT services they
Kokesh J, Ferguson AS, Patricoski C. received either through
“Preoperative planning for ear surgery
using store-and-forward
telemed or direct referral.”
telemedicine”. Otolaryngology-Head Mike Comerford, Audiologist,
and Neck Surgery, 143:253-
257, 2010. Yukon Kuskokwim Health Corporation

87.  Low hanging fruit is still
fruit.
 Take it
 Talk about it
87

88.  If you often say “There must
be a better way” there
probably is
 Look for these in terms of
telemedicine
88

89. Take your best ideas and build on them.
89

90. Traveling a Provider to Promote Efficiency and Rapid
Delivery of ENT Care Through Telemedicine
Kokesh J, Ferguson AS, Patricoski C, LeMaster B. “Traveling an Audiologist to Provide Otolaryngology
Care Using Store-and-Forward Telemedicine”. Telemedicine and e-Health, 15(8):758-763, 2009.

95. Patient Cost
Visits
Traveling Audiologist Program 1,987 ($175,000)
Patient Travel Prevented 1,726 $697,090
Based on Outcomes of:
• Did patient still need to travel to field clinic?
Assumptions: Note: 1,153
• Only travel to hub is being saved.
• Escort required if patient less than 18 years old
less than
• No lodging / per diem calculated 18 yrs old
Net Savings in Travel Costs $522,090
Realized by Program (300% ROI)

96.  Proven technology
 High unmet need
 No other good solutions
96

97.  Evolve successes to predictable levels of
clinical service
 Find and support (but don’t solely rely on)
your clinical champions
 Clinical protocols matter
 But it’s all about RELATIONSHIPS
97

98. Champion Service Model
 Can  Guarantee of performance
◦ See potential  Agreed upon expectations
◦ Create
 Sustainable and scalable
◦ Innovate
◦ Nurture  Accountable
 Can’t  Independent of
◦ Sustain individuals
◦ Grow to large scale  Requires support
◦ Leave something behind structure
98

99.  Multi-provider, multi-region, multi-
organization, multi-jurisdiction, patient
participant….
 Focus on integrating with the way providers
work and formalizing relationships and
mutual responsibilities:
◦ Who accepts referrals?
◦ Do they have specific data requirements?
◦ How fast must they answer?
◦ How do you track what is happening?
◦ How is everyone paid?
◦ Who gets notified and must respond when the
patients telemetry data tanks?
99

100.  Software can
help drive
clinical
protocols
 Essential for
program
development
100

101. 2.6 cases/month 7.9 cases/month Almost
10
250 more
Avg Monthly Caseload
8
patients
6 are being
4 seen per
2 year, a
0 savings in
-48 -36 -24 -12 0 12 24
80 man-
years of
TIME Relative to CME/Training (months)
Before CME After CME
waiting
time.
AVG (Before) AVG (After)
101

102. Misunderstanding incentives
The workload / capacity mismatch
“In addition to” versus “Instead of” trap
102

103. 103

105.  Know the incentives for
behavior within your
system, and make sure that
they on in alignment with
what you are trying to
accomplish
 If they are not, change the
incentives or move on to a
different project.

106. You may be “too
successful”
System usage
may grow faster
than you can
grow capacity
Have contingency plans – short and long term

107. Frame telemedicine
12

Median Time per Case (min)
as a better way to
10
8
do existing work, 6
not just additional 4
work 2
Provide appropriate
0
 Sep-02 Sep-03 Sep-04 Sep-05 Sep-06
incentives
 Don’t reward work
well done with
more work

108.  If you are not a clinician, “Live a
day” with your clinician(s)
 Knowing the work, the
workflow, the systems within
which they work will provide
you a huge advantage
 Build
trust, understanding, rapport
108

109. … what we learned,
and what we did right and wrong.

110. … don’t get so caught up in the “doing” that you
neglect to reflect, speak and write about what
you have done so far.

111. Annual Provider Usage
(by Experience)
1,000
800
# Providers
600
…early on and 400
forever. And over 200
and over again.
0
2001 2002 2003 2004 2005 2006 2007 2008 2009
Return New

112. Don’t be afraid to pull and reallocate
resources.

113. Make sure you have the expertise and tools
you need at the outset

114. Goodwill eventually runs out.

115. Where does Telehealth fit into the
“Health Information Exchange?”

116. WHAT IS HOT
CONNECTED HEALTH
AFHCAN’s success in the past has been by ourselves
AFHCAN AFHCAN
server server
AFHCAN’s future success will be based on
how well our system can work with others

117. The goal of HIE is to
Health Information
There VtC S&F
ExchangeaccessTheand
facilitate (HIE) to
retrieval of clinical data to
mobilization of healthcare
provide safer, more
information electronically
Space timely, efficient, effective, e
across organizations within
a region, patient-centered
quitable, community or
care.
hospital system.
Here “Classic” EHR/ EMR
Now Soon Time Future
117

118. 118
118

119. “Network of Networks”
being developed to provide a secure, nationwide, interoperable health
information infrastructure that will connect providers, consumers, and
others involved in supporting health and healthcare
HISPC Electronic Health Record (EHR) Laboratory Results Reporting
IS 01:
Policy The02: Biosurveillance
IS Health Information
Security and Privacy Empowerment
IS 03: Consumer
Collaboration
IS 04: Emergency Responder Electronic Health Record (ER-EHR)
HITSP Consumer Empowerment and Access to Clinical Information
IS 05:
Standards via Media
Healthcare Information
IS 06: Quality
Technology Standards Panel
IS 07: Medication Management
IS 08: Personalized Healthcare
CCHIT Consultations and Transfers of Care
IS 09:
Certification Certification Commission for
IS 10: Immunizations and Response Management
Healthcare Information
IS 11: Public Health Case Reporting
Technology
IS 12: Patient – Provider Secure Messaging
IS 77: Remote Monitoring

120. Samples:
C32 – Summary Document Using HL7 CCD
May include administrative
(e.g., registration, demographics, insurance, et
c.) and clinical (problem list, medication
list, allergies, test results, etc) information
C48 – Encounter Document
AFHCAN will be Supports the process of sending patient
going live with encounter data (excluding laboratory and
radiology)
C32 interfaces to
EHRs statewide C74 – Remote Monitoring Observation
Medical information collected by remote
later in 2010. monitoring management systems from
monitoring devices and/or device
intermediaries
C84 – Consult and History & physical note
Support the exchange of information from a
consulting provider to a referring provider;
and may also be used to provide background
information from a referring provider to a
consulting provider
120

122. 2003-2009
Blending
Specialties
Store & Live
Forward VtC
Remote
Monitoring

123. 2010 
Technology
Blending
Store & Live
Forward VtC
Remote
Monitoring

124. Traditional Devices
+ New Connectivity
+ New Messaging
= NEW SOLUTIONS 124

125.  Recognize that needs and
technologies will shift during
the lifetime of your system.
 Constantly re-assess your
program.
 Look for the next thing.
125

126.  Telehealth is a clinical mandate, not a technical
initiative.
 Provide a predictable level of service (with scarce
clinical resources).
 Support local planning and decision making.
 Provide state/national coordination, planning
and accountability.
 Create efficiencies through centralized services.
 Leverage existing expertise.
126

127. Thank You
John Kokesh, MD Stewart Ferguson, PhD
Department of Otolaryngology Alaska Federal Health Care Access
Alaska Native Medical Center Network (AFHCAN)
4315 Diplomacy Drive Alaska Native Tribal Health
Consortium
Anchorage, AK 99508
4000 Ambassador Drive
Anchorage, AK 99508
(907) 729-1416
jkokesh@anthc.org
(907) 729-2262
sferguson@anthc.org
AFHCAN, Alaska Native Tribal Health Consortium, Anchorage, AK