Telemedicine In Arkansas: A Rural State s Experience

Transcription

1 Telemedicine In Arkansas: A Rural State s Experience Julie Hall-Barrow, Ed.D. University of Arkansas for Medical Sciences Center for Distance Health

2 Medically Underserved Areas In a state where 73 of 75 counties are designated as medically underserved, healthcare access is the most overwhelming reason for Arkansas poor health standing. AR Dept. of Health and Human Services, 2006

3 Telemedicine Model Providers Offer Community Needs-Based Services Centralized Tech Support & Scheduling Call Center 24/7 Telemedicine Network & Infrastructure Evaluation / Research Case Coordination & Evidence Based Guidelines / Protocols

4 Two Successful Models Antenatal & Neonatal Guidelines, Education and Learning System Arkansas SAVES (Stroke Assistance Through Virtual Emergency Support)

5 ANGELS in Action

6 Funding of ANGELS A contract that began in 2003 with Arkansas Medicaid The overall goal is three-fold: Increase healthcare access Impact on costs Improve quality of care

7 ANGELS Mission To ensure that every woman in Arkansas, at risk of having a complicated pregnancy, receives the best possible perinatal care.

8 ANGELS Tele-Health Sites: 2010 Tele-Nursery Clinical Services

9 Triage Call Center Facilitates process in obtaining MD & Hospital acceptance of transport Coordinates transport services whether ground or air Communicates with Care Providers until arrival of patient to tertiary center

10 Tele-Nursery Currently, 18 clinical telemedicine units are in rural hospital nurseries for: M,W,F daily census Transport updates Back-transport assessment Real-time neonatology consults

11 Tele-Nursery Pre-transport consults Back-transport evaluations Genetic consults

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13 Mom and Baby Connection

14 Technology Employed at UAMS Site Equipment Tandberg Edge HDTV High definition camera Connectivity 1.5 Mb/s T1 internet line Additional Equipment All sites conference 4 Codian MCU bridges Conference Recording Tandberg content server

15 What is TOUCH? T-elemedicine O-utreach U-tilizing C-ollaborative H-ealthcare o Jefferson Regional Hospital Pine Bluff, Jefferson County o Mercy Medical Center Rogers, Benton County o National Park Medical Center - Hot Springs, Garland County o Ouachita County Medical Center Camden, Ouachita County o St. Bernard s Medical Center Jonesboro, Craighead County o St. Edwards Ft. Smith, Sebastian County o St. Michael s Texarkana, Miller County o Washington Regional Medical Center Fayetteville, Washington County o Willow Creek Women s Center Johnson, Washington County

16 Opportunities Save 5 lives per year for every 50 neonates <1000 grams delivered appropriately in Arkansas 21% decrease in mortality of all VLBW neonates Save 7 severe IVH per year for every 50 neonates delivered appropriately in Arkansas In US, 75% of VLBW newborns are delivered in smaller nurseries If only 25% delivered in these smaller nurseries, potential for 3000 lives saved

17 Since Implementation of Telemedicine Rounds Attended 585 times (TOUCH only show below) Yielded 61 consults Aided in 15 transports Gave F/U 90 times Answered 43 questions Confirmed most common OB complications (PTL, PROM, pre-eclampsia) TOUCH Attendance TOUCH Attendance (linear) Linear regression revealed a significant increase in attendance (p=<0.0001).

18 Angel Eye A one-way, real-time video and audio feed broadcasted bedside from the UAMS neonatal intensive care unit to a web site only accessible to family and selected hospital staff, aimed to support families separated from their hospitalized newborn.

19 Angel Eye

20 Changes in Patterns of Delivery for LBW Infants in Rural / Outlying Areas Highest-risk infants residing >80 miles from UAMS were more likely to be delivered at UAMS after ANGELS implementation (26% increase in 2005) ANGELS Regression-adjusted estimates controlling for maternal risks, insurance source, socioeconomic characteristics, and race/ethnicity. p<0.05

21 Improved Outcomes for High-risk Infants Delivered at Specialized Perinatal Centers P<0.01 P<0.05 P>0.10

22 ANGELS Awards Agency for Healthcare Research and Quality (AHRQ) Model replication 2006 Harvard Ash Institute for Democratic Governance, Innovations in American Government Award, Top 50 finalist 2007 Harvard Ash Institute for Democratic Governance, Innovations in American Government Award, Top 18 finalist 2007 AT&T Center for Telehealth Research and Policy at UTMN, Hugo Gernsback Award for Clinical Innovation 2007 American Telemedicine Association Innovations Award for the Advancement of Telemedicine

23 What have we achieved? Increase in the % of high-risk OB cases identified in every region of Arkansas, including rural areas Neonatal mortality rates for Medicaid declined after ANGELS, from 4.5 per 1000 to 3.3 per 1000 AR SAVES increased delivery of tpa from <1% to 23% in participating hospitals Created new approaches to health care overall

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25 Why Arkansas? First nationally for stroke mortality 58.8 per 100,000 residents Arkansas had 1,847 strokerelated deaths in 2006, which dwarfs Arkansas other major causes of death US Stroke Mortality Rates ( , Adults Age 35 Years and Older) by County (Source:

26 What is Arkansas SAVES? Arkansas SAVES Stroke Assistance through Virtual Emergency Support

27 Tele-Stroke

28 Arkansas SAVES: Purpose Increasing subspecialty access to Arkansas stroke patients Impacting stroke-related disability and mortality Enhancing emergent stroke support by consulting on the administration of t-pa medication to eligible patients

29 Arkansas SAVES: Rationale Hospitals without the support of a neurologist often forgo administration of t-pa The time needed to affectively administer t-pa is often lost when transporting patients Arkansas stroke patients are missing out on this quality-of-lifesaving drug

30 Tele-Stroke Pool of neurologists

31 Telemedicine Equipment Spoke Site Physician s Home

32 AR SAVES Pilot Sites Central Arkansas UAMS Medical Center, Pulaski County, Little Rock, AR (Hub site) Arkansas River Valley Sparks Health System, Sebastian County, Fort Smith, AR (Hub site) Johnson Regional Medical Center, Johnson County, Clarksville, AR (Spoke site) Western Arkansas Mena Regional Medical Center, Polk County, Mena, AR (Spoke site) Booneville Community Hospital, Logan County, Booneville, AR (Spoke site)

33 Rural Emergency Room This is just an incredible step forward. Now we can go in and minimize, and potentially completely reverse, the effects of a stroke. Bill McCourtney, M.D., Emergency Room Medical Director Mena Regional Health System

34 Stroke Sites Year 1 Hub Sites UAMS, Little Rock Sparks, Ft. Smith Spoke Sites Johnson Regional Clarksville Mena Regional Mena Booneville Community Booneville McGehee Desha Hospital McGehee DeWitt Hospital DeWitt Helena Regional Helena W. Helena Baxter Regional Mt. Home White River Med Batesville BMHC Arkadelphia

35 Current AR SAVES Sites

36 Acute Stroke Therapy Tele-stroke Scenario EMS or triage nurse identifies acute stroke victim and notifies local ER physician ER physician confirms acute stroke (history and exam) ECG, Labs, CT scan Ischemic Stroke Other Large ICH Tumor ICH SAH Tele-stroke system activated; online connection leading to 2-way viewing between patient, local physician, patient s family and stroke neurologist at remote site Risk / benefits discussed; CT / Labs reviewed IV t-pa given if appropriate. Other aspects of acute management decided. Monitored care plan set up Patient treated locally. Can be transferred if needed. Request for transfer Case reviewed (history, exam, CT, Labs) Given poor condition and prognosis, ER physician and family advised against transfer Transfer

37 Iva Sikes Mena Regional Medical Center

38 State-wide Image Repository To improve access and reduce the burden for consulting neurologists a state-wide repository for CT scans of AR SAVES patients was created. This repository allows for quick access to the CT image without retrieving images for individual hospital PACS systems.

39 Roles of Spoke Facilitators Paid for participation 30% nurse 20% IT Program communication Participation in monthly interactive meetings Coordinates with AR SAVES staff Training Mocks Follow-up

40 Public Education Billboards Radio Churches Schools Community Organizations Dedicated Personnel

41 Non-traditional Methods Over 10,000 community members educated

42 AR SAVES Data

43 Data Total Consults 328 Total t-pa to

44 Iva Sikes Mena, AR

45 What s Next $102 Million BTOP grant to expand broadband to an additional 474 sites in AR including all Community Colleges. South Central Telehealth Resource Center Trauma

46 Program Acknowledgements Arkansas Department of Human Services Medicaid Arkansas Department of Health Video Network UAMS Center for Distance Health Curtis Lowery, Director Tina Benton, Clinical Division Director

47 Thank You