Balancing Technical, Political, and Organizational Issues within Your Telemedicine Program

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Balancing Technical, Political, and
Organizational Issues within Your Telemedicine
Program Ronald S. Weinstein, M.D. Michael
Holcomb Arizona Telemedicine Program
Disclosures Apollo Telemedicine DMetrix
UltraClinics
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Western Governors Association Telemedicine
Action Report - 1995Barriers

• Infrastructure, Planning Development
• Telecommunications Regulation
• Reimbursement for Telemedicine Services
• Licensure Credentialing
• Medical Malpractice Liability
• Confidentiality

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Founders of The Arizona Telemedicine Program
Richard A. McNeely Ronald S. Weinstein, M.D.
Rep. Robert Bob Burns John J. Lee
Rep. Lou-Ann Preble Rachael
Anderson
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Founded in 1996
100,000 cases in 2004
60 subspecialties
7 National Awards
45 Grants/17 million/150 publications
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Governance
Virtual Corp
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Arizona Telemedicine Council
Governance Non-statutory over-arching authority
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Arizona Telemedicine Council
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Arizona Telemedicine Program

• 150 Sites
• Native American Healthcare (Navajo,
• Apache, Hopi, and others)
• Prisons and their service providers
• Jails
• Non-IHS Rural Hospitals
• Community Health Centers
• Schools
• Distance Learning Affiliates
• International sites

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Action Items
1996

• Implement a regional telecommunications strategy
  for telehealth.
• Draft a comprehensive telehealth business plan.
• Establish a Telemedicine Training Program.
• Develop telemedicine standards for Arizona

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Action Items
1996

• Implement a regional telecommunications strategy
  for telehealth.
• Draft a comprehensive telehealth business plan.
• Establish a Telemedicine Training Program.
• Develop telemedicine standards for Arizona

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Telemedicine Program Core Components
Strategic Planning
Administration
Medical Services
Telemedicine Training
Distance Education
Financial Affairs
Legal Affairs

Network Operations
Assessment
Inter- institutional Relations
Marketing Public Relations
Governmental Affairs
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Business Plan
Application Service Provider Enterprise
Client Layer
Professional Services Layer
Operations Services Layer
Infrastructure Services Layer
Vendor Services Layer
Membership based
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Application Service Provider Enterprise

• Client Layer
• Patients
• Payers
• Businesses

• Professional Services Layer
• Provider (physician, nursing) services
• CME/CE/distance education
• Clinical protocol development
• QA/QC programs
• Credentialing, licensing services
• Legal services

• Operations Services Layer
• Telemedicine clinic operations
• Telemedicine equipment installation
• and operational support
• Telemedicine practice management
• Medical record services
• Transcription services
• Billing services

• Infrastructure Services Layer
• Telecommunications infrastructure
• Enterprise-wide PACS system
• Grant writing
• Customized marketing

• Vendor Services Layer
• Outsourced services
• Physical infrastructure (T1 lines)
• Device development

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ATP Membership Special Benefits
Universal Services Fund Reimbursement Program

ATP Service Provider Status
Special Targeted Programs
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Unique Branding Opportunity
Action Items
1996

• Implement a regional telecommunications strategy
  for telehealth.
• Draft a comprehensive telehealth business plan.
• Establish a Telemedicine Training Program.
• Develop telemedicine standards for Arizona

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Rural site simulator
Consultants module
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Rural site simulator
Consultants module

• Over 500 graduates
• 50 Organizations

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Telemedicine Training Where Branding Takes
Place!!
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Promote state-wide interoperability across all
healthcare organizations in Arizona.
Action Items
1996

• Implement a regional telecommunications strategy
  for telehealth.
• Draft a comprehensive telehealth business plan.
• Establish a Telemedicine Training Program.
• Develop telemedicine standards for Arizona.

Arizona Telemedicine Technology Assessment Center
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Action Items
1996

• Facility Design
• Vendor Selection

Standard Operating Procedures
Applications Clearing House

• Implement a regional telecommunications strategy
  for telehealth.
• Draft a comprehensive telehealth business plan.
• Establish a Telemedicine Training Program.
• Develop telemedicine standards for Arizona.

Arizona Telemedicine Technology Assessment Center

• Basic and Clinical Research
• Grants and Contracts

• Clinical Practice Protocols
• Best Practice Guidelines

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Arizona Telemedicine Program

• Telehealth Services

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• Teleradiology
• 25,000-35,000 cases in 2002
• Navajo reservation-
• 12 Hospitals
• Emergency cases
• Mammography
• CT
• MRI
• Apache reservation-
• 182,000 savings
• from avoided
• Air Vacs from a single hospital.

Telehealth Services 60 subspecialties
Tuba City IHS
Ganado
HOPI
Kingman
CHP
FMC
ASPC Winslow
Springerville
VVMC
Payson
Parker
ASPC Florence Eyeman
ADC
ADC HQ
COM
ASPC Perryville
Whiteriver IHS
PIMC
ASPC Lewis
Globe
ASPC Safford
Panama
TBC
PET
ASPC Yuma
PCC
Yuma
Tucson
RHO
St. Marys
Alvernon
Kino
St. Elizabeth
ASPC Douglas
Sierra Vista
Douglas
Nogales
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• Teleradiology
• 250,000 cases
• 22 Hospitals
• Navajo reservation-
• Hospitals Mammography
• CT
• MRI
• Apache reservation-
• 182,000 savings
• from avoided
• Air Vacs from a single hospital.

Tuba City IHS
Ganado
HOPI
Kingman
CHP
FMC
ASPC Winslow
Springerville
VVMC
Payson
Parker
ASPC Florence Eyeman
ADC
ADC HQ
COM
ASPC Perryville
Whiteriver IHS
PIMC
ASPC Lewis
Globe
ASPC Safford
Panama
TBC
PET
ASPC Yuma
PCC
Yuma
Tucson
RHO
St. Marys
Alvernon
Kino
St. Elizabeth
ASPC Douglas
Sierra Vista
Douglas
Nogales
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Teledermatology
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Telepsychiatry
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Sara Gibson, M.D.
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Corrections Healthcare
Infectious diseases
Telepsychiatry
Teledentistry
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School telenursing - Primary Care Consultation
Left Lynnette Cook, the school nurse at Lowell
Elementary School (at 1121 South Third Street) in
Phoenix uses a digital otoscope to examine the
ear drum of a student with an ear ache. Right a
pediatrician in Tucson, at a Community Health
Center in Tucson (insert) examines the ear drum
on a video monitor and renders a diagnoses.
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Waiting for a donor heart
Left Heart transplant patient in Gilbert,
Arizona, waiting for a donor heart at home. The
patient is describing his condition to his
surgeon in Tucson by video conferencing. Right
Dr. Jack Copeland, an international expert in
heart surgery, at University Medical Center in
Tucson, talks to the Gilbert patient by
telemedicine. Using telemedicine, months of
hospitalization were avoided by this patient
waiting for a transplantation at home. Once a
donor heart was procured, the patients
operation in Tucson was a success.
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Home Health - Ostomy Care
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Arizona Telemedicine Program

• Telehealth Services

• Arizona Telemedicine Program Brand
• High tech medicine
• Entreprenurial
• PragmaticVisionaries
• Inventing the future, here in Arizona

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A case study in telehealth innovation, technology
transfer, and commercialization
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Ultra-rapid Digital Mammography
Tuba City, AZ
Tucson, AZ
Ultrarapid Digital Mammography 6000 cases 45
minute TAT 75 of cases 90 minute TAT 100 of
cases
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Ultrarapid Beast Cancer Service
Digital Mammography Teleradiology
Surgical Consultation
Breast mass detection
Surgery
Mammography
Telepathology
Tissue processing __________________ Rapid HE
staining
Consolidated pathology report
Oncology Teleconsultation
Objective Reduce total time from weeks to same
day service
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Ultrarapid Beast Cancer Service
Surgical Consultation
Breast mass detection
Surgery
Mammography
Telepathology
Tissue processing __________________ Rapid HE
staining
Consolidated pathology report
Oncology Teleconsultation
lt 4 hours
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Virtual Slide Image Acquisition
Raster scanning
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Arizona Ultrarapid Virtual Slide Project

• Virtual Microscopy
• Specifications
• lt1 minute virtual slide processing times
• Totally automated system
• Innovations
• Miniaturized optics
• Ultraprecise fabrication
• Novel digital camera system
• Parallel image processing
• Very large databases

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field-of-view
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tissue
glass slide
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GLASS SLIDE
PATHOLOGY WORKSTATION
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Arizona Team Decoupling of FOV and magnification
can be achieved through miniaturization.
Video microscope
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United States One Cent Coin
Lenslet
Challenge to fabricate aspheric lenslets 1.0 to
1.5 mm in diameter
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Concept rendering for an array microscope AZ
Optical Sciences Center
7 mm
Weinstein et al, Human Pathology, 2001
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Ultrarapid Virtual Slide Telepathology

• Array Microscope
• Specifications
• lt1 minute virtual slide processing times
• Totally automated system
• Innovations
• Miniaturized optics
• Ultraprecise fabrication
• Novel digital camera system
• Parallel image processing
• Very large databases

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http//www.optics.arizona.edu
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Invention
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array microscope based on aspheric optics
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DMetrix Lenslet Array
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Invented in Tucson, Arizona
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DMetrix Virtual Slide Imaging System
240,000 images per second
24 megapixel camera
lenslet array ensemble
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Lenslet array
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Field of view
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Scanning simulation
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RD 100 Award

• multiple patents

DMetrix Ultrarapid Virtual Slide
Processor Manufactured in Tucson, AZ
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Example of a DMetrix virtual slide
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A case study in telehealth innovation, technology
transfer, and commercialization
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University Medical Center
Establishment of the ultrarapid throughput
womens health clinic May, 2005
University Physicians Hospital
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University Physicians Hospital at Kino Tucson,
Arizona 5/5/05
1110 A.M.
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University Medical Center
University Physicians Hospital

• Patient
• Surgeon
• Processing Lab

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University Physicians Hospital at
Kino State-of-the-art Rapid Through-put
Laboratory- May 2005
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Super-rapid tissue processor
DMetrix DX-40 Virtual Slide Scanner
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University Medical Center

• Telepathologist
• Teleoncologist

University Physicians Hospital

• Patient
• Surgeon
• Lab

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Ultrarapid Beast Cancer Service
Hospital A
Tissue processing __________________ Rapid HE
staining
Surgical Consultation
Breast mass detection
Breast Biopsy
Telepathology
Hospital B
Oncology Teleconsultation
Pathology Report
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Telepathology University Medical Center Tucson,
Arizona
Achyut Bhattacharyya, M.D. Director of Surgical
Pathology University Medical Center Tucson,
Arizona
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Virtual Slide
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University Medical Center Tucson, Arizona
University Physicians Hospital at Kino
324 P.M.
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University Physicians Hospital at Kino Tucson,
Arizona
326 P.M.
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University Physicians Hospital at Kino Tucson,
Arizona
327 P.M.
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Ana Maria Lopez, M.D., M.P.H., Medical Director
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Patients Comments

• I believe this program will be a benefit to many
  people who are unable to travel to see a
  specialist or who would feel better with results
  in a couple of hours. I found this service
• to be excellent in so many ways!!!
• Carol Peaks
• May 5, 2005

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Dr. Ronald S. Weinstein briefs U.S. Senator John
Kyle on plans to implement the first ultrarapid
throughput womens health clinic
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• White House Executive Briefings
• by special invitation

February 3, 2005 White House Indian Treaty Room
Discussions of Arizona Telemedicine Programs
eHealthUTM , UltraClinicsTM and THealthTM
projects with Assistant Deputy Secretary of
Defense, Steven L. Jones, M.D. and Telemedicine
Director for DoD COL Ron Poropatich, M.D.
Members of the Arizona Telemedicine Program
Executive Team at the White House Ms. Sandy
Beinars, Mr. Ron Pace, Dr. Ronald S. Weinstein,
and Dr. Ana Maria Lopez
Telemedicine Program Project Presentations
Four Corners Telemedicine Consortium
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• Healthcare system franchiser
• Same-day healthcare services
• One stop shopping
• Telemedicine-enabled
• Ultra-rapid labs and radiology services
• On-line second opinions

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