TELEHEALTH IN MONTANA

Transcription

1 TELEHEALTH IN MONTANA John Zauher THE NEED FOR TELEHEALTH Montana, the fourth largest state in the United States, is sparsely populated with the 2000 census showing 902,195 residents scattered over a vast geographic area roughly equivalent to the area of Japan. According to county demographic profiles, over 80 percent of Montana s communities have populations of less than 3,000 people. Ninety-six percent of Montana s 56 counties are designated either frontier or rural by federal definition (typically meaning fewer than seven persons per square mile). In addition, all or part of 41 of Montana s 56 counties are designated as Health Professional Shortage Areas (HPSAs), Medically Underserved Areas (MUAs) and Mental Health shortage areas by the U.S. Department of Health and Human Services. Like other rural areas, many of Montana s communities have limited health care and less public transportation compared to urban areas. There also are fewer social services or other needed services for people with disabilities. Compounding this dismal picture are long travel distances and poor secondary roads, long winters and inclement weather, a scarcity of rural health-care providers, economic decline and an aging population base. Telecommunications is one way of bridging the barriers to providing care for these rural populations. Research and experience suggest that the smallest and least adequate facilities have the need for telemedicine consultations, yet they have the fewest resources for the start-up costs associated with purchasing

2 RURAL HEALTH CARE IN JAPAN AND THE UNITED STATES: SHARED CHALLENGES AND SOLUTIONS videoconferencing systems. Factors contributing to the problems of rural health-care systems and communities are: the inability to recruit and retain health-care providers; geographic barriers to rural residents access to health care ; the tendency for rural residents to leave the local community for healthcare services; the financial drain on the local economy when patients and health-care providers go to urban centers to receive health-care services and training; professional isolation the inability of rural health-care providers to regularly interact with their urban colleagues; having to be on-call all of the time, without relief; the need to keep up with the advances of medicine and not having the latest equipment; and limited access to continuing medical education programs often needed to maintain national board certifications. Many of the factors that relate to difficulty in accessing specialty care in rural areas apply equally well to mental health care services. Psychiatrists are in particularly short supply in Montana, with 43 of the state s 56 counties having no psychiatrists. TELEHEALTH NETWORKS IN MONTANA Montana has four active telehealth networks, all of which participate in the Montana Healthcare Telecommunications Alliance (MHTA), which was formed in The purpose of the MHTA is to support and advance the use of telecommunications in health care in Montana. MHTA goals include the pursuit of cost reduction relative to the operation of telemedicine networks, the promotion of interoperability between systems, promotion and development of services, legislative and policy influence and collaborative work in research and evaluation. St. Vincent Healthcare, a principle organizer behind the case study described in this paper, is a regional referral center located in Montana s largest city, Billings. The city also is the largest in a 500-mile radius. St. Vincent Healthcare operates a number of programs designed to help address problems related to the delivery of rural medical care while supporting the primary care providers in its service area. Examples include a fixed wing and helicopter advanced life support and air ambulance transport service, outreach physician services that 140

3 TELEHEALTH IN MONTANA John Zauher provide 80 clinics per month, and locum tenens (temporary, part time) physician service. The Partners in Health Telemedicine Network (PHTN) was conceived as an additional outreach program designed to meet the needs of the rural communities served. The Partners In Health Telemedicine Network has been operational in Montana since The mission of PHTN is to support the development of healthier communities in Montana through the collaborative, creative use of technology to improve health care, communications and education in a cost effective manner, with access for all. PHTN uses two-way, interactive video telecommunications technology to deliver a variety of telehealth services to support not only the rural/frontier health facility, but the community and surrounding county. Telemedicine is viewed as one of several service categories supported by interactive video telecommunications. Others include physician medical education, continuing education for nursing and other health-care professionals, community health education, business meetings, family visitations, support groups and delivery of university courses. By combining advanced technology with services that meet a broad base of community needs, the economic viability of the community and surrounding region can be improved. PHTN is structured as a hub and spoke network with the primary hub site located at St. Vincent Healthcare in Billings. St. Vincent Healthcare, Holy Rosary Healthcare (Miles City, Montana) and St. James Healthcare (Butte, Montana) are owned and operated by the Sisters of Charity of Leavenworth Health System in Leavenworth, Kansas. Primary network technical support, operations, scheduling and program development are the responsibility of the Telehealth Services Department at St. Vincent Healthcare. Organizationally, Telehealth Services reports directly to the vice president of Medical Affairs who also chairs the Telemedicine Advisory Council for the network. Secondary hubs include hospitals located in Miles City, Butte, and Lewistown, Montana. Spoke sites include smaller hospitals and clinics, some of which are owned by St. Vincent Healthcare. PHTN currently serves Native American populations on all seven of Montana s Indian Reservations through a dedicated link to the Indian Health Service Area Office in Billings (Figure 1). PHTN is also directly linked to the Benefis Health System, located in Great Falls, Montana. Benefis operates an 141

4 RURAL HEALTH CARE IN JAPAN AND THE UNITED STATES: SHARED CHALLENGES AND SOLUTIONS independent telehealth network, which includes 10 rural sites in north/central Montana. PHTN also has dial-up capabilities to other Montana and U.S. telehealth networks. In the past PHTN has conducted telemedicine consults with Virginia Mason Medical Center in Seattle, Washington, and the University of Minnesota medical school. One of the network s business applications included an interview link between a business in Billings and a receiving site in London, England. Figure 1. Partners in Health Telemedicine Network Browning Fort Belknap Wolf Point Poplar Great Falls - REACH Montana Network Hub Lewistown Butte Harlowton Absarokee Bridger Billings Hardin Crow Agency Lame Deer Miles City Ashland Red Lodge Lodge Grass Wind River, WY Montana Regional Partners Indian Health Services Partners DEMOGRAPHICS The rural sites on the existing PHTN network were chosen based upon recognized limited resources, the degree of interest in the project expressed by contacted communities and the ability of the carriers to provide the necessary telecommunications network connections to the selected communities. Table 1 provides profiles of all existing sites as of mid-2001 and proposed sites through The table also includes the road mileage from each to the regional tertiary care centers in Billings. 142

5 TELEHEALTH IN MONTANA John Zauher Table 1. Participating Facility Profile PARTNERS IN HEALTH TELEMEDICINE NETWORK COUNTY COMMUNITY FACILITY NAME # of Beds Avg. Daily Census % Occup. Round Trip Miles to Tertiary Billings Current Sites BIG HORN Hardin MT Hardin Clinic 92 Crow Agency MT Indian Health Services Crow Indian Not Available 120 Hospital CARBON Bridger MT Clark Fork Medical Center 86 Red Lodge MT Mountain View Medical Center 125 CUSTER Miles City MT Holy Rosary Hospital % 288 FERGUS Lewistown MT Central Montana Medical Center % 250 ROSEBUD Ashland MT Ashland Community Health Center 244 Lame Deer MT Northern Cheyenne Service Unit in Not Available 208 Lame Deer SILVER BOW Butte MT St. James Community Hospital % 445 STILLWATER Absarokee MT Absarokee Medical Center 107 WHEATLAND Harlowton MT Wheatland Memorial Hospital % 185 YELLOWSTONE Billings MT Saint Vincent Hospital and Health Center Proposed Sites % 0 JUDITH BASIN Stanford MT Basin Medical Center 314 POWDER RIVER Broadus MT Powder River Medical Clinic 330 WASHAKIE Worland WY Washakie Medical Center 30 WY Daily Census Not Available 1054 Inpatient Admits Proposed Sites 2003 GALLATIN Bozeman MT Bozeman Deaconess Hospital % 283 MUSSELSHELL Roundup MT Roundup Memorial Hospital and % 102 Nursing Home PARK Livingston MT Livingston Memorial Hospital 228 Source: CY 98 Montana Department of Public Health and Human Services, County Health Profiles Report and CY 1999 COMP data, MHA (Association of Montana Health-Care Providers

6 RURAL HEALTH CARE IN JAPAN AND THE UNITED STATES: SHARED CHALLENGES AND SOLUTIONS TECHNOLOGY Currently, PHTN utilizes a dedicated, T1 network with Madge video telecommunications switches. The end point devices are either VTel or Polycom video teleconferencing systems (codecs) that are dual H.320 and H.323 standards compliant. The network features an open architecture, allowing partners to connect not only within the dedicated environment but also through the public switched video network to national or international locations. Network sync (clocking) is acquired from the AT&T public net T1 circuit with a secondary AT&T T1 as backup. Madge telco switches are smart programmable devices that allow segmentation of the channels. Where appropriate, and to gain a more cost-effective use of the 24-channel T1, the circuits are split to allow 12 dedicated channels for video telecommunications. The remaining 12 channels are utilized for other services such as teleradiology, voice or information systems applications. Scheduling a 16-site network is a challenge. Network growth over the next two years may add additional sites. PHTN is currently evaluating several Internet-based scheduling programs. An integrated, Web-based scheduling application will reduce costs and also provide better documentation for tracking telemedicine transactions. An Internet-based evaluation component will also be assessed to allow sites to enter evaluation data via the Internet. The time frame from R&D to market has shortened significantly for new technologies. In addition, market prices for these devices have reduced dramatically while product capability and quality has increased. Original codec/video systems were purchased at $80, Current codec/video system prices range upward from $7, each. Interoperability in the early 1990s was a challenge because of proprietary algorithms. Systems are now International Telecommunications Union (ITU-T) standards-based, but proprietary issues still exist and impact not only point-to-point communications but also multi-point (MCU) communications. The traditional U.S. telehealth scenario has been full motion, interactive T1 or ISDN-based networking. Integrated data, voice and video networks will become more prevalent as ATM (asynchronous transfer mode) and other technologies are deployed and made available on a broader scale in rural/ frontier locations. PHTN has tested store-and-forward, Internet-based telemedicine in a collaborative project involving the Johnson Space Center of the National Aeronautics and Space Administration (NASA) in Houston, 144

7 TELEHEALTH IN MONTANA John Zauher Texas. This demonstration project involved the use of a Telemedicine Instrumentation Pack (TIP) designed by Wyle Labs, Inc., and flown on the NASA Space Shuttle Endeavor. The TIP unit (Figure 2) is the size of a small suitcase, with an embedded computer and proprietary software that captures and displays patient audio, video and data for telemedicine consultations. The unit weighs 40 pounds and is comprised of four subsystems. The imaging subsystem includes a chargecoupled device (CCD) video camera that attaches via a common interface with all TIP lens systems, including the otoscope, opthalmoscope and macrosope. Lighting is provided by a single fiberoptic light source. Images are displayed on a full-color, flat panel display. Figure 2. NASA Telemedicine Instrumentation Pack The audio subsystems include an electronic stethoscope and audio signal output to an external speaker. The data acquisition and management subsystem provides electrocardiogram, heart rate, percent oxygen saturation and blood pressure. The subsystem also provides data storage, forward and retrieval. 145

8 RURAL HEALTH CARE IN JAPAN AND THE UNITED STATES: SHARED CHALLENGES AND SOLUTIONS TELEMEDICINE APPLICATIONS PHTN completed the NASA/TIP demonstration project in September Forty-three Native American patients were examined in their homes. Many of these patients did not have access to telephone communications or automobile transportation. As a federally designated frontier area, the Northern Cheyenne Reservation has many sites accessible only via rough roads and difficult terrain. There was a strong, favorable response by patients to the TIP examination in the home, and several technical issues regarding home use of the TIP were identified and corrected. A complete review of the project in an article entitled Bringing Space Medicine Down to Earth is currently pending publication. 1 PHTN is also interested in pursuing lower cost storeand-forward technologies in an ongoing attempt to match the most costeffective technology with medical needs. The PHTN strategy for full-motion video telecommunications was to develop education and administrative utilization of the network and systems. This would create an opportunity for building awareness and familiarity with the tool. PHTN then completed physician/practitioner surveys and approached physicians who expressed support for telemedicine. By building successes, PHTN expects other physicians and practices to begin participating in opportunities provided by the network. Currently, PHTN utilizes fullmotion video for the delivery of telemedicine specialty and mental health consults. Teleradiology will be an added value to the consults. PHTN utilizes the same T1 circuits to deliver video consults and, where appropriate, teleradiology. Video telecommunications systems will be placed directly in the specialty practices of Orthopedics, Dermatology, Perinatology and Mental Health. Competency-based training will be provided to users. Telemedicine will then become a routine part of the physician s daily practice. The network will continue to measure travel savings and patient and physician satisfaction. PHTN also plans to measure specific clinical outcomes and related economic benefits. 1 Scott C. Simmons, Jeannine B. Rant, John Zauher, Cindy Leenknecht, Diane Jeanotte and P. Vernon McDonald, Bringing Space Medicine Down to Earth, Telemedicine Journal, publication pending. 146

9 TELEHEALTH IN MONTANA John Zauher BARRIERS Some of the key barriers to the successful use of telemedicine have been: inadequate reimbursement; lack of comprehensive physician support; cost of telecommunications circuits; unreliable or unavailable broadband services; lack of technical standards; and regulatory issues. SOLUTIONS Federal, state and private payers have been slow to recognize the value of telemedicine. One of the primary government payers, Medicare, will begin reimbursement for telemedicine, in effect, on the same basis as a face-to-face consult, beginning October 1, The Medicaid program in Montana currently reimburses for telemedicine along with many of the major third party payers. It is expected that new opportunities for reimbursement will encourage more physician support. In focus groups and through written surveys, physicians have made teleradiology their number-one request. Consequently, the addition of teleradiology as an adjunct to the video consult will also impact physician participation. Integrating current office practice, policies and procedures into the telemedicine process will also positively impact physician support and use of telemedicine. Ultimately, physicians have indicated that they want telemedicine at the desktop. This will require a broadband Internet solution that incorporates a standardized, secure electronic patient record with aural, visual and textual information. In Montana, T1 circuits are distance sensitive and priced accordingly. For instance, a T1 circuit from Ashland to Billings may cost approximately $3,000 per month. This cost is prohibitive for a small facility struggling to sustain payroll and other clinic operational costs. Universal Service funding from the U.S. government has attempted to create more reasonable pricing by establishing a national fund to offset the high cost of advanced 147

10 RURAL HEALTH CARE IN JAPAN AND THE UNITED STATES: SHARED CHALLENGES AND SOLUTIONS communication services (T1/Fractional T1) in rural/frontier areas. The same T1 circuit from Ashland to Billings with Universal Service funding may only cost approximately $500 per month. Although more reasonable, this is still a hardship for many small health-care facilities. Another opportunity to reduce telecommunications costs is a strategy of collaborating with other networks to create an integrated Montana State health-care network. It would then be possible to take the aggregate bandwidth of all networks to the table and solicit competitive bids from various carriers. However, because of limited business opportunities in many rural states, competition, by itself, may never successfully drive down the cost of advanced services. Although Montana now has several carriers, and more competition than 10 years ago, the deployment of advanced services in many small frontier towns is unlikely to occur. Advanced communication satellite technology such as fullduplex KA band may provide a future answer for isolated frontier areas. Many of the carriers in Montana are small companies with a single technician assigned to support network operations across a vast geographical area. Also, some carriers are reluctant to provide Quality Of Service (QOS) or Service Level Agreements (SLA) for advanced services. PHTN consistently encourages carriers to provide QOS/SLA for advanced services. In the future, MHTA could also provide leverage on this issue, especially in cooperation with the Montana Public Service Commission, which is responsible for developing policy. Such issues as system downtime due to network difficulties or lack of redundancy have varying levels of acceptance according to the type of service provided, i.e., education, meetings, or telemedicine. Although PHTN adheres to H.320 and H.323 and associated ITU-T standards for video telecommunications, there have been very few technical standards developed specifically for telemedicine. Teleradiology has wellconceived Digital Imaging and Communications in Medicine (DICOM) standards for electronic transmission and display of radiographic information. PHTN has established policy for a minimum data rate of 672 Kbps (kilobits per second) for all medical consults. However, issues remain relative to the entire spectrum of technical interaction including network equipment, video system (codec) and display system specifications and their relationship to 148

11 TELEHEALTH IN MONTANA John Zauher specific medical disciplines. Telemedicine users through their professional technical associations can initiate activity in this area. Regulatory agencies such as the Food and Drug Administration are targeting telemedicine equipment and systems for review as possible clinical devices. The Joint Commission on Accreditation of Healthcare Organizations recently issued telemedicine guidelines relative to credentialing and privileging. PHTN has been active with the Montana State Board of Medical Examiners in developing telemedicine licensure. The practice of telemedicine across state borders is another regulatory issue that impacts licensure and credentialing of physicians. Laws vary from state to state, and federal regulation is being considered by the American Medical Association and other organizations. Other regulatory policies will follow as telemedicine is integrated into the health system as a commonly accepted method of practice. 149

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