# Presentation: 687872

## AFHCAN Project

**AFHCAN Project**

**Stewart Ferguson, Ph.D**
- Associate Project Director
- Director of Technology
*AFHCAN Project Office*
*Alaska Native Tribal Health Consortium*
*907-729-2260**	**	**www.afhcan.org*

## AFHCAN Sites

## AFHCAN Partners

**IHS** - 194 sites - 97,000 beneficiaries
**VA** - 1 site - 65,000 beneficiaries
**US Army, US Air Force** - 9 sites - 47,000 military and dependents
**USCG** - 4 sites - 3,000 beneficiaries
- Alaska **PHN** - 26 sites

## “Remoteness” by Access

## Cost of Travel

## “Types of Sites” by Staffing

## NLM - Maniilaq Data

- 11 Village clinics
- Begin: 	1/26/1999
- Gather:	1/15/2001
- 2863 Cases
- 8594 Images
- 3393 Video otoscope (40%)
- 5061 Digital camera (60%)

## Lessons Learned from NLM...

**Software too difficult**
***“******If you don’t use it regularly, then you will forget how to use it”***

**Radio Medical Traffic**
***“******20 cases in 30 minutes”***

## Radio Medical Traffic

- Daily telephone calls
- 90 seconds / consult
- Telemedicine facilitates this process

## “Telemedicine involves the transfer of health data over a telecommunications system.”

**What is Telemedicine?**

**“****Telemedicine involves the transfer of health data over a telecommunications system.”**

## Workload Distribution

## What are your key organizational goals for telehealth applications?Please rank in order of importance to your organization:

- Access to care
- Patient Satisfaction
- Quality of Care
- Information Transfer
- Costs/Economics
- Continuity of Care
- Other

## Slide 13

## AFHCAN Referrals

## Slide 15

## AFHCANet

- Alaska Native Medical Center (1)
- Veterans Administration Medical Center (1)
- Maniilaq Health Corporation (13)
- SouthEast Regional Health Consortium (12)
- Kodiak Area Native Association (6)
- Eastern Aleutian Tribes (8)
- Norton Sound Health Corporation (15)
- Public Health Nursing (?)
- Yukon Kuskokwim Health Corporation (47)
- Bristol Bay Area Health Corporation (30)
- Dialup connectivity (up to 23)
- Commissioned - EAFB (1)

## Slide 17

## Slide 18

## VoIP - Anchorage Dial Tone

- Provide 24 dial tones in Anchorage
- Integrate T1 into PBX at sites:
- SEARHC, KANA, NSHC, MHC
- Least cost routing
- Monitor traffic and cost savings:
- NSHC spends >$2000/mo
- T1 cost ~$900/mo
- 24 dial tones ~$25/mo each

## AFHCAN SYSTEM

**CLINIC**

**NETWORK**

**AFHCAN SYSTEM**

## Slide 21

## Sustainability

- Organization owns equipment
- Training provided on:
- Assembly, testing, burnin
- Software installation / management
- Clinical design
- Clinical usage

## 1) Keep it Simple.

- 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

## 2) Make it Sustainable and Supportable.

- Easily maintained
- Open source design (.CFM)
- State Machine
- Centralize “Point of update” or “Point of Code”
- Web solution - NO custom clients
- remote upgrades
- Minimize initial and recurring costs
- No ongoing licenses

## So many organizations ...so many software issues!

- >1000 Workstations
- >100 Servers
- WinNT, Win2000, Unix, Linux
- IE3, IE4, IE5, Netscape, Xwindows
- POTS to T1 connectivity
- Different patient encounter forms
- RPMS / CHCS / VISTA / Meditech
- Funds disappear in 2 more years

## A properly designed system can improve the quality of health care delivery without saving or sending a single byte.

## Satellites

- Add 0.6 seconds to roundtrip delay
- Cause web pages to load in 5 - 40 seconds
- Solutions:
- Remove need for frame sets
- Caching locally
- TCP/IP registry tweaks
- Different IP stack
- IE (http) registry tweaks
- 3rd party software (e.g. Flash Networks) - mostly proxy/spoofing techniques
- 3rd party hardware

## Slide 28

## Effect of Proxy / SSL

## Alaska Federal Health Data SharingPlanned Project Relationships

**What the AFHCAN software**
**is not ...**

## AFHCAN Evaluation

- Usage - all
- Evaluation questions - all
- Voice over IP - SEARHC, KANA, NSHC, MHC
- PE Tube Followup - MHC
- Video Conferencing - SEARHC
- Ear Disease - YKHC
- FAS Clinic - SCF

## FAS Clinic (SCF)

- Team Approach - based on University of Washington’s nationally recognized model
- Pediatrician
- Pediatric Psychologist
- Physical Therapist
- Speech and Language Therapist
- Social Worker
- Parent Navigator / Advocate
- Clerk
- Coordinator

## FAS Clinic (SCF)

- Purpose - Develop diagnosis and treatment plan for FAS
- Method - Interviews with parent and child
- Technology
- VtC (digital one way mirror)
- Nikon 990 (dysmorphology)
- Future - travel team, travel equipment

## PE Tubes

## PE Tube Followup

- National standard - 4 month followups
- Reality - 8 month or longer
- Expect up to 90% of followups can be accomplished with reverse telemedicine
- Is an image as good as an “on site” visit?
- Two independent “on site, in person” assessments.  Take images
- 6 and 12 weeks later, conduct assessments from images alone.
- Compare inter-provider variability, “on site” versus “image” assessment and treatment plans

## Core Principles

**	****ENHANCE the interoperability of disparate ****	****	****telehealth systems and applications.**
**	****IMPROVE the sustainability and usability of such ****	****systems in future years.**
**	****Provide a mechanism for meeting current and ****	****	****projected FUTURE needs for data security**
- www.hss.state.ak.us/atac

**Core Principles**

**Alaska Telehealth Advisory Council - Technical Standards Workgroup**

## ACKNOWLEDGEMENTS

**ACKNOWLEDGEMENTS**

**Technical Expertise and Design**
- Tom Bohn
- Jim Rogina
- Chris Patricoski, MD
- AFHCAN Statewide Committees
**Funding Sources**
- DHHS - OAT
- VA
- U.S. Army
- IHS
**Legacy**
- NLM / UAA