Chinle Service Unit Approaches to Telemedicine …Chinle Service Unit Approaches to Telemedicine...
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Chinle Service Unit Approaches to Telemedicine During the COVID- 19 Pandemic Stephen Neal, PA-C, Chief Of Staff, Chinle Service Unit (CSU), Informatics Indian Health Service
Transcript of Chinle Service Unit Approaches to Telemedicine …Chinle Service Unit Approaches to Telemedicine...
Chinle Service Unit Approaches to Telemedicine During the COVID-
19 Pandemic
Stephen Neal, PA-C, Chief Of Staff, Chinle Service Unit (CSU), Informatics
Indian Health Service
Navajo Nation Diné Bikéyah
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• 27,000 mi2 (~the size of West Virginia)
• Largest Reservation in USA and most populous 1
• 2010 census 160,000 living on the reservation
• 30% without running water or indoor plumbing 2
• 10%-20% lack access to power
• Geographically isolated
• High poverty index
Canyon De Chelly: Chinle
Photographer: Ansel Adams
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• 55 bed hospital/ outpatient facility
• Federal facility in the middle of the reservation
• Approximately 120 members on the medical staff
• 40,000 outpatient visits annually
• 25,000 ER visits annually
• Main 3rd party payor is Medicaid, >2/3 of our visits
• Indian Health Services ( IHS )
Location: Chinle
Photographer: Nina Ritchie
Pink is the CSU
The Chinle Service Unit (CSU)
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Services at the CSU
Emergency Med
OB/Gyn/Midwifery
General Surgery
Anesthesia
Pharmacy lab
Radiology
Native Medicine
Public health Dept
Cardiology
Family Medicine
Internal Medicine
Pediatrics
School-based Teen Clinic
Dental
Optometry
Physical Therapy
Occupational Therapy
Audiology
Nutrition
Infectious Disease
Psychiatry Adult/Child
Counseling Services
Integrated Behavior Health
Speech Language Pathology
Everyone practices to the full scope of their license Location: Chinle
Photographer: Nina Ritchie
5Saving Lives. Protecting Americans.
SARS-CoV-2: Covid-19
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Heat map of reservation July 24; 2193
cases in Chinle
Apache County 4050
per 100,000
July 24
Multiple deployments: FEMA, National Guard, and others
Lock down and curfew
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Series1
Challenges of COVID-19
• March 6th Public Health Emergency
• Outpatient services closed
• Underserved and marginalized patient population,
many with comorbidities
• Increasing number of cases/testing
Lots of challenges, maybe we could apply
telemedicine as a solution?
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A perfect storm… if you will
Location: Chinle
Photographer: Nina Ritchie
Telemedicine Set-up Pre-COVID
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• Some telemedicine equipment had already been purchased and ready to plug in: DX80 Codec dedicated to
audiovisual, 8865(VOIP w Camera)
• Cisco call manager for VOIP communications (Phone calls over the internet)
• CSU campus has adequate internet (~25 mbps)
• Cisco Web RTC telepresence platform had been developed by HIS
Home-grown, user-friendly platform met federal security requirements
• FirstNet
Cisco IP Phone 8865 DX 80
Challenges with Telemedicine at CSU
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• AZ is #36th State in Broadband coverage in USA 2
• The state average is 79 mbps
• Only 0.16% of Apache County residents has access to 25 mbps…
• The next lowest in AZ is la Paz 51.7%
Apache
La Paz
What is broadband?
High speed Internet access via numerous modalities (i.e. Fiber, DSL,
Cable, Fixed Wireless (Cellular))
Our patients lack access to reliable, affordable broadband
CSU Telemedicine Response to COVID-19
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• Novel application in multiple domains:
Specialty Clinics
Primary Care high risk case management group
Respiratory Clinic
Emergency Department
• Nephrologists on the reservation generally visit several sites across
the Navajo Nation
• Concern about providers exposing patients due to multiple site visits
• Patient population is largely elderly and high risk
• Canceling clinics meant patients would have to travel off-reservation
for specialty care (>100 mi one way)
• CSU set up telemedicine for nephrology clinics to address concerns
raised by the pandemic
• Some resistant to adopting telemedicine
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Specialty Clinics and COVID-19
Nephrology
Location: Chinle, Lukachukai, Tsaile
Photographer: Nina Ritchie
Yaadila = “Good Grief”
• 7 Nephrologists participated
Get VPN access for them to chart in our system (i.e. place orders, review
results etc)
Train on the telemedicine platform
Have access to IT support to troubleshoot issues
• Benefits of CSU telemedicine set-up:
One of our most high-risk patient populations was able to be seen during
pandemic while minimizing the risk of exposure to COVID-19
Operational with in 10 days
No fancy equipment, just a computer (web camera, internet, microphone) and
cisco meeting platform
Patients still must come to the facility for visit although reduced, still some
risk.
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Specialty Clinics and COVID-19
Nephrology
TM HACK TIP:
1. Stakeholders are fundamental in the process: Nephrologists were resistant to the change. Clinic nurse supervisor and
hospital admin supported it. Currently, ALL the nephrologists love it.
2. Use what you have: Telemedicine equipment was on back order, a basic desktop worked well.
• CSU has a risk stratified group of primary care patients that have identified
as warranting more intensive case management
High-risk patients with multiple co-morbidities, low health literacy,
few resources and/or of concern to their PCPs
• Patients are often difficult to reach, lacking reliable phone or internet
access
• Phone visits are not ideal for addressing complex problems
• In-person visits less desirable given importance of protecting these high-
risk patients from exposure to COVID-19 at the hospital.
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Primary Care Challenges Due to COVID-19
Location: Chinle, Spider Rock
Photographer: Nina Ritchie
Bringing Broadband to End-Users
• FirstNet
• IHS has an Enterprise Mobile Service Program with FirstNet
• Federal program established in 2012 giving First
Responders priority in communication priority access to
available cellular networks, greater security, and other
benefits
• https://firstnet.gov/about (please see website for details)
• Public private partnership with AT&T
• FirstNet is for:
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“First responders receive access to resources first, ahead of others. And there’s no throttling
for FirstNet users anywhere in the U.S. In times of crisis, first responders within the network
get first access to necessary resources through the automatic preemption capabilities of the
network.”
Primarily:
Fire, Law Enforcement
EMS, PSAP, EMA
Extended examples:
Healthcare, utilities,
transportation
Location: Chinle
Photographer: Nina Ritchie
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• IHS HQ offered the CSU 2 tablets with access to FirstNet to explore novel
uses of this technology
• PCPs were asked to pick which of their high-risk patients most needed to
be seen
• Tablets were taken to patients’ homes via Navajo Nation health promotions
staff for telemedicine visits
• Able to have multiple providers see a patient in a single visit Diabetes
educators, Behavioral Health, Podiatry, PT, OT… etc.
• Small number (n = 20) but growing and well received
• Feedback:
Patients loved having their needs met in the field and avoiding COVID-19
exposure
Providers got time with complicated patients and maintained critical primary
care bonds
Tablet Program & COVID-19
TM HACK TIP:
3. Get input: Providers “If we had vitals this would be great for CHF patients…”
4. Build on what's working: Expanding to CHF clinic
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• Large volume of respiratory cases demanded a new approach
• Patients vitals taken roomed and have visit from a on campus via
“remote” provider.
• Benefits:
Decreased PPE burn rate
Reduced contact with patients and therefore also probability of quarantine for
providers
Able to involve higher risk providers in patient care
High throughput High testing rate and rapid triage
High volume of billable visits (5,300 since March)
Rapid provider uptake of telemedicine platform
Respiratory Clinic & COVID-191/…
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RESPIRATORY CLINIC
Total Encounters >5,300 94% seen via telemedicine
Point to Point:
1. Via audio-video phone call between patient and provider
all located on campus
2. Had our telemedicine platform set up in the room and
just kept rooming patients.
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We implemented Telemedicine in 4 environments with 2 basic
architectures:
Point to point on premises
• VOIP Phone call with Video
• Meeting space set up with
• Patients cycling through
Summary
Billing Licensure
• Arizona Medicaid already has generous reimbursement for
telemedicine visits Right now everyone does, no better time to
try innovating!
• We are federal facility; licensure is less critical (We take all)
• Medicare reimbursement structure likely to change
External
• Tablets using FirstNet
Future potential for the CSU and Telemedicine
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Pipeline for the future Potential Growth (Ideas)
• Tele ICU
• Tele Stroke-Center (similar sized institutions have shown
return on investment, decrease in LOS, and decrease
mortality)
• Lactation (take home tablet and return)
• Hospice (take home tablet and return)
• Outfit EMS with Tablets for in the field consults
• What else…?
• Expanded use of tablets
• Field Clinic Kiosks
Chapter Houses, Senior Centers, etc.
• Additional Specialty Services:
Asynchronous Dermatology
Rheumatology
Endocrinology
Telemedicine is not a panacea, but it will be part of the future of healthcare delivery
TM Life Hacks
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Advice
What Would I Do, If I Were You?
• Consult Telehealth Resource Centers (TRC)
Regional organization i.e. NATA
• Needs assessment, start where you need it
• I have a problem, is there a virtual solution?
• What do you really need?
Broadband Rural or city has options
Devices tablets $200-$400, vs dedicated audiovisual
equipment
Platform Large market out there, find one that meets your
needs
• If we can do it, so can you…
Use whatever internet you have
Start small and grow from there
Fail fast and frequently… reassess and adapt
Involve stakeholders
Remember Distance prevents… but Telemedicine can bridge
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