Telehealth in Minnesota: At a Crossroads

Transcription

1 Telehealth in Minnesota: At a Crossroads Stuart Speedie, Ph.D., Health Informatics, University of Minnesota and the Fairview University of Minnesota Telemedicine Network Karen Welle, M.A.P.A., Office of Rural Health & Primary Care, MN Dept of Health September 6, 2006

2 The Basics of Telehealth Telecommunications Link Geographic Distance

3 Telehealth and Telemedicine: Telemedicine : Use of ICT to provide clinical services when participants are at different locations. Telehealth: A broader application of ICT to distance education, consumer outreach, etc.

4 Current Telehealth Areas Specialty consultation Direct patient care Grand rounds Staff training and education K-12 and postsecondary health care education Patient education Correctional health

5 Telehealth Examples Telemental health Telepsychiatry Home telehealth Teledermatology Teleradiology Telepharmacy School health Patient Education Teledentistry Emergency consults Cardiology e-icu care Long term care Telerehabilitation Corrections Staff Education

6 Live, Interactive Telehealth

7 Videoconference Equipment

8 Digital Stethoscope

9 Store & Forward Reviews Consult Report Completes Consult Report Secure Server Dermatologist

10 Home Telehealth

11 TelePharmacy Satellite model Hospital or retail audio/video connection to satellite location; pharmacy technician dispenses drugs under pharmacist supervision Remote site model Prepacked meds released by main pharmacy from cabinet at remote site

12 Benefits High patient satisfaction Patients remain in the community Employers see fewer lost work hours Easier access to specialty care Better medical outcomes Practitioner support primary to specialty Reduced travel time and costs

13 Patient Outcomes: Admissions to A higher level of care TeleHomeCare 17% Control 42%

14 What s going on in Minnesota?

15 FAIRVIEW-UNIVERSITY OF MINNESOTA TELEMEDICINE NETWORK Littlefork Medical Center, Littlefork Bigfork Community Hospital, Bifork Internl. Falls Range Regional Health Care Ctr, Hibbing Cook Community Hospital, Cook Cuyuna Regional Medical Center, Crosby Crookston Cass Lake Riverwood HealthCare Center, Aitkin Tri-County Hospital, Wadena Wheaton Mercy Hospital and Health Care Ctr, Moose Lake Providers Ne-Ia-Shing Clinic, Onamia Fairview-University Medical Center, Minneapolis Kanabec County Mora Mille Lacs Health System, Onamia Fairview Medical Center, Red Wing

16 Telemedicine Sites

17 New Connections for Community Mental Health Partners: Blue Cross & Blue Shield of Minnesota United Behavioral Health Tele-Community Development/DHS

18 Community Mental Kittson Roseau Roseau Baudett e Health Centers and Hallock Lak e of the Marshall Woods International Fall s Warren Beltr ami Services Thief River St. Louis Fall s Koochiching Po l k Cook East Gr and For ks Pennington Lak e Red Lake Blackduck Red Lake Itasca Crookston Fall s Ely Grand Marais Foss ton Virginia Bemi dji Norman Mahnomen Bagley Hibbing Silver Bay Mahnomen Ada Grand Rapids Walker Becker Two Harbors Clay Detroit Aitkin Duluth Lakes Park Rapids Moorhead Crow Carlton Superior Cloquet Cass Wing Ai tkin OtterTail Wilkin Wadena Staples Pine Todd Br ai ner d Mille Br eckenridge Fergus Falls Long Morrison Lacs Anoka Forest Lake Pr airie Anoka Grant Douglas Hinckley Elbow Alexandria Little Falls Milaca Maple Grove Lake Po p e Stearns Benton Br aham 15 New Hope Wheaton Rush City Minnetonka Minneapolis(7) Starbuck Sti llwat er Cambridge Cr ys tal Stevens Oak Park Trav er se Sher burne Morris Glenwood Cr ys tal Heights St. Cloud Isanti Center St. Louis Park Oakdale St.Paul(6) Elk River City Big Stone Hennepin 24 Waconia Ri chfield Swift Cottage Grove Kandiyohi Wr ight Meeker Chaska Bl oomi ngton Benson Ortonville Willmar Carver Buffal o Eagan Madison Chippewa Litchfield Montevideo McLeod Scott Dakota Lac Qui Parle Renville Granite Falls Yellow Medicine Glencoe Olivia Canby Redwood Sibley Red Wing Ivanhoe Lyon Fall s Gaylord Le Sueur Goodhue Lake City New UlmNicollet Le Center Marshall Sleepy Eye Faribault St.Peter Wabasha Redwood Rice Wabasha Springfield Pipestone Murray Brown Kasson Mankato Waseca Dodge Rochester Winona Cottonwood Waton wan Blue Earth Owatonna Windom Madelia Pipestone Slayt on St.James Waseca Steele Olmsted Winona LaCrescent Rock Nob les Martin Freeborn Preston Jackson Blue Earth Mower Luverne Jackson Aust in Caledoni a Fairmont Faribault Albert Lea Fi l l more Houston Worthington Li ncol n Cl ear water Hubbard Wadena Kanabec Chisago Ramsey Washington

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20 Telepharmacy: Wilderness Healthcare Coalition St. Luke s Duluth and Mercy Hospital, Moose Lake Riverwood Healthcare Center, Aitkin Community Memorial Hospital, Cloquet Lakeview Memorial Hospital, Two Harbors Cook Hospital, Cook Deer River Health Center, Deer River Big Fork Valley Hospital, Big Fork Ely-Bloomenson Hospital, Ely Recently added additional members

21 More telehealth in Minnesota Good Samaritan, numerous others home telehealth VA telemedicine, home telehealth Gillette Children s Hospital Sister Kenny Institute telerehabilitation Other Regional Initiatives South Country Health Alliance 9-county Local Public Health initiatives South Central (Blue Earth) 30+ organizations Mental health Southwest Mental Health Initiative

22 Minnesota e-health Initiative Advisory Committee - Private-public collaboration meeting since October 2005 Vision: Accelerate use of HIT to: Improve health care quality Increase patient safety Reduce health care costs Enable individuals and communities to make best possible health decisions

23 MN e-health Initiative Empower consumers to make informed health and medical decisions Focus: Personal Health Records Interconnect providers and communities Focus: Secure Health Information Exchange/ Electronic Health Records Protect communities Focus: MN-PHIN prevention resources, rapid disease detection and response Enhance infrastructure Focus: Broad, includes supporting rural and underserved communities and Telehealth

24 MN Critical Access Hospital (CAH) 2006 HIT Survey MN CAHs using Teleradiology Responses % Yes 41 79% No 11 21% Total % N=52

25 Provider Reimbursement Live, Interactive Consults Largely covered at face-to-face rates Teleradiology Complete coverage Other Store and Forward Some coverage for specific areas Home telehealth Allowed but not specifically and separate reimbursed. Technology Costs Small originating site fee allowed

26 Reimbursement Specifics Private Insurance Almost universal for specialty consultations Medicare Restricts payment to patients seen in hospitals/clinics, but not long term care Home telehealth: allowed but not reimbursed Medical Assistance Home telehealth: will pay for skilled nurse with realtime audio-visual connection Some counties: small fixed monthly payment Corrections telehealth: done on contract basis Other: provider or grant-funded

27 Why it s important for rural? Health workforce shortages Mental health providers Specialty care providers Pharmacists Nurses Long distances Costly windshield time for providers Travel expense and time for patients Lost employee work time

28 Challenges and barriers Isolated, uncoordinated efforts Referral patterns and existing business arrangements Provider indifference Integration with EHR systems Equipment and user costs Technical support Concerns about quality of care Broadband network availability Security Practitioner reimbursement The business case

29 Why talk about this now? The Drivers Broadband infrastructure expansion Electronic Health Records expansion Reimbursements improving Universal Service Fund assistance Government and foundation funding Declining equipment costs Patient needs for medical care

30 What s missing? State level strategies and leadership Mechanisms for collaboration and coordination Accessible resources for networking, support, training Integration with HIT initiatives An inventory of telehealth services and providers Consistent coverage policies

31 DISCUSSION

32 TELEHEALTH in OTHER STATES

33 Kentucky TeleHealth Network Active since 1994 Initial funding sources: OAT, ARC, and local foundation. Network legislatively mandated in 2000 $292K/year state funding for operations $1,000 stipend for certain network members for communication line charges.

34 Kentucky TeleHealth Network University of Kentucky and University of Louisville + 3 regional interconnected hubs, with connections to: Rural hospitals and primary care clinics Public school health clinics Public health departments Community mental health centers (over 70 sites) State psychiatric hospital connected to several community mental health centers All sites pay to be part of the network Features online scheduling

35 Nebraska Statewide Telehealth Network FUNDING 2004 $70,000 Nebraska DHHS grant to Nebraska Hospital Association (NHA) to begin coordinating resources $500,000 Nebraska DHHS grant funding for equipment and support Other funding: Office for the Advancement of Telehealth and the Central and Northern Nebraska Area Health Education Center $900,000/year Nebraska Public Service Commission: Universal Service Fund covers over 80% of the annual transmission costs $100/month by participating rural hospitals Hub sites receive total reimbursement for leadership and facilitation

36 Nebraska Statewide Telehealth Network 68 rural hospitals 8 regional referral hospitals 7 Omaha metropolitan hospitals 19 public health departments 3 mental health centers + 1 hospital 6 bioterrorism labs Pending: prison acute care hospital, Indian Health Services, and rural health clinics

37 Nebraska Statewide Telehealth Network Nebraska Hospital Association University of Nebraska Medical Center Nebraska Information Network Public health departments Nebraska AHECs State of Nebraska Health & Human Services, Education, Public Service Commission Telecommunication providers *A formal decision making or governing body is being researched

38 Nebraska Statewide Telehealth Network Phase 1 Nearly completed Connection of individual facilities to statewide network. Phase II - Starting Address operations and governance Web-based system for scheduling and training

39 Arizona Telemedicine Program University-based telemedicine services distance learning informatics training technology assessment Customers: rural communities, Indian tribes, and rural prisons Starting 1996, $1.2 million state funding

40 Arizona Telemedicine Program Real-time and store-and-forward technologies in 20 communities Continuing education in 34 communities Home health care Pediatric occupational/physical therapy Telenursing services in Phoenix schools.

41 Arizona Telemedicine Program: Project Nightingale Dedicated broadband healthcare infrastructure that functions as a telecommunications collaborative. Provides access to T-1/ATM telecommunications on a private network throughout the state on a cost-sharing basis.

42 Alaska

43 Collaboration of federal agencies formed in Department of Veteran's Affairs (VA) Department of Defense (DoD) Department of Homeland Security (U.S. Coast Guard -USCG) Indian Health Service (IHS) Alaska Native Tribal Health Consortium (ANTHC)

44 Alaska Federal Health Care Access Network Began 1998 Statewide satellite-based IP network reaching to nearly 200 sites 42 connected servers throughout Alaska Store and forward technology Tech support and training AFHCAN Carts at remote sites

45 Established 1999 Provides forum for collaboration and communication between organizations involved in telehealth initiatives ATAC members include: State of Alaska Alaska Native Tribal Health Cooperation University of Alaska Telecommunication companies Hospitals Health care organizations Federal agencies Payers Co-chaired by Commissioner of the Department of Health and Social Services and Chief Tribal Officer of the Alaska Native Tribal Health Consortium.

46 Alaska DHSS:Telehealth Advocates for the development of telehealth Collects and disseminates program information Liaison between federal, state or private organizations Identifies laws, regulation and reimbursement practices that serve as barriers Identifies gaps in services and helps develop solutions Partners with Medicaid services to increase billing for T/H services Assesses impact of telehealth initiatives on access to health care

47 1994, public-private partnership 82 sites in 40 counties Network funded with federal, state, and institutional dollars + support from all sites Semi-private network using IP over T-1 for: audio/visual clinical encounters data transfer for teleradiology store and forward Any site can connect directly with another

48 33 Hospitals 11 Mental Health Clinics 1 Mental Health Hospital 2 Rehab Hospitals 24 Federally Qualified Health Care Centers 1 Urgent Care Clinic 1 Home Health Agency 2 Schools of Medicine 1 School of Nursing 1 School of Health Related Professions 1 Outpatient Cancer Ctr 1 Army Hospital 1 Nursing Home 1 State Habilitation Ctr

49 Missouri Telehealth Resource Center Housed at University of Missouri Funded by one-time $3.4 million state appropriation from tobacco settlement $$ Formal training center and curriculum Any site receiving state funding required to attend formal training on legal, regulatory, administrative and operational issues Ongoing funding:???

50 California 1994: Launch of California Telehealth/Telemedicine Coordination Project 1996 recommendation: Need for statewide resource center to facilitate and promote the development of Telemedicine programs and networks

51 California Telemedicine & ehealth Center Established July 1997 Three years start-up funding provided by 2 local foundations March 1999, $5 million grant from The California Endowment; 34 mini-grants were funded.

52 California Telemedicine & ehealth Center 1999, Telemedicine Learning Center (TLC) established. Partnership with University of California, Davis Medical Center Provides professional training in telemedicine protocol, implementation, and technique.

53 California Telemedicine & ehealth Center 2003, 5-year $9 million grant from The California Endowment to: develop, expand and support networks provide training and technical support for rural providers , $630,000 from the California HealthCare Foundation and $1,020,530 Match from Blue Shield of California Foundation

54 California Telemedicine & ehealth Center Program Focus: Develop, sustain and expand regional delivery networks Support the expansion of rural Telemedicine and ehealth sites Expand professional ehealth training and mentoring Provide technical assistance to current and future Telemedicine and ehealth sites

55 California Telemedicine & ehealth Center Maintain statewide ehealth Inventory on ehealth Create a comprehensive catalog of CTEC resources Identify opportunities for policy changes to enhance reimbursements and expand access in rural regions Serve as key resource for advanced integration of technologies into health care organizations Build a solid business organization and infrastructure

56 DISCUSSION